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foundation 


Annual  Report 


1921 


061 

R682R 

1921 


j|Rockefeller  Foundation 

61  Broadway,  New  York 


4 


THE  LIBRARY 


The  Ontario  Institute 


for  Studies  in  Education 


Toronto,  Canada 


■■<;  ^:  \-.    ■^:'f-' 


THE  ROCKEFELLER  FOUNDATION 
Annual  Report  for  1921 


The 
Rockefeller  Foundation 

Annual  Report 


1921 


The  Rockefeller  Foundation 
61  Broadway,  New  York 


CONTENTS 

THE  ROCKEFELLER  FOUNDATION 

PAGE 

President's  Review 1 

Report  of  the  Secretary 75 

Report  of  the  Treasurer 339 

INTERNATIONAL   HEALTH    BOARD 

Report  of  the  General  Director 85 

Appendix 159 

CHINA  MEDICAL    BOARD 
Report  of  the  Director 243 

DIVISION   OF   MEDICAL    EDUCATION 
Report  of  the  General  Director 311 


ILLUSTRATIONS 

PAGE 

Map  of  world-wide  activities  of  the  Rockefeller  Foundation 4-5 

Full-time  health  workers  in  United  States,  1921 15 

Professional  training  of  health  officials 17 

Students  at  work  in  the  bacteriological  laboratory  of  the  School  of 

Hygiene  and  Public  Health  of  Johns  Hopkins  University 25 

Class  in  protozoology,  Johns  Hopkins  School  of  Hygiene  and  Public 

Health 25 

Architect's  drawing  of  proposed  new  building  to  house  the  School  of 

Hygiene  and  Public  Health  of  Johns  Hopkins  University 26 

The  "Pay  Clinic"  of  Cornell  University  Medical  College 26 

Staff  and  students  of  the  Peking  Union  Medical  College 41 

Academic  procession  at  dedication  of  the  Peking  Union  Medical 

College 42 

A  part  of  the  academic  procession  at  the  dedication  of  the  Peking 

Union  Medical  College,  September  19,  1921 42 

Map  used  in  anti-malaria  campaign  in  Louisiana 58 

Yellow  fever  map  of  the  Western  Hemisphere 96 

Scene  of  violent  yellow  fever  epidemic  in  Peru  during  1921 98 

Three  aspects  of  yellow  fever  control  effort  in  Peru  during  1921.. .  .  101 
A  small  model  showing  the  types  of  water  containers  used  about  the 

dwellings  in  Merida,  Yucatan 102 

Driven  well  for  preventing  Stegomyia  breeding,  Nicaragua 102 

Map  of  Mexico  and  Central  America  showing  towns  visited  by  yellow 

fever  in  1921 105 

Yellow  fever  cases  in  Mexico  and  Central  America,  1920  and  1921. .  106 
What  malaria  has  cost  the  towns  of  Bamberg  and  Chester,  South 

Carolina,  during  the  years  1918  to  1921 110 

Reduction  in  physicians'  calls  for  malaria  in  Groveton  and  South 

Groveton,  Texas Ill 

Record  of  malaria  incidence  for  town  of  Hamburg,  Arkansas 113 

How  malaria  has  been  brought  under  control  in  Crossett,  Arkansas  114 

Tuberculosis  exhibit  at  Pasteur  Institute,  Paris 117 

Traveling  educational  units  in  anti-tuberculosis  work,  France 118 

The  hookworm  story  of  Richmond  county,  Virginia 122 

Decline  in  incidence  of  dysentery  and  typhoid  fever,  Troup  county, 

Georgia . , 125 

Appropriations  of  legislatures  to  state  boards  of  health  in  eleven 

southern  states,  1910-1921 126 

Control  of  hookworm  disease  as  result  of  campaign  measures  applied 

in  1918  in  Jacarepagua,  Brazil 128 

vii 


VIU       THE  ROCKEFELLER  FOUNDATION 

Reduction  of  hookworm  disease  as   result  of  control  measures, 

Governor's  Island,  Brazil 128 

Effect  of  treatment  and  installation  of  latrines  on  severity  of  hook- 
worm infection 129 

Increase  in  funds  for  rural  sanitation  appropriated  by  Federal  and 

local  governments  in  Brazil,  1917-1921 130 

States  of  Brazil  that  have  funds  available  for  a  program  of  rural 

sanitation 131 

Reduction  of  hookworm  infection  rate  on  estates  in  Jamaica 132 

Carrying  the  gospel  of  sanitation  to  the  natives  of  Solomon  Islands  137 

Group  of  Moors  assembled  at  village  dispensary,  Ceylon 137 

Three  phases  of  field  operations  against  hookworm  disease  in  Papua  138 

Counting  hookworms  expelled  by  treated  patients 147 

Group  assembled  at  typhoid  exhibit  at  Prague 147 

Counties  having  full-time  health  officers  at  close  of  1921 148 

Localities  visited  in  Madras  Presidency,  India 162 

Incidence  of  bowel  complamts,  Trichlnopoly  jail,  India,  1918  to  1921  164 

Worms  harbored  by  1,878  prisoners  in  Trichlnopoly  jail,  India .  .  .  165 

Ancient  temples  in  Slam  put  at  service  of  hookworm  commission  .  .  167 

Groups  of  natives  assembled  for  treatment,  Tuplle,  Panama 168 

Average  number  of  worms  harbored  by  seventy-four  coolies  at  work 

on  the  Mudis  tea  estates,  Madras  Presidency,  India 170 

Number  of  patients  in  Lionel  Town  hospital,  Jamaica,  1918-1921.  .    171 

Effect  of  hookworm  treatment  In  Rio  Cobre  Home,  Jamaica 172 

Hemoglobin  indices  of  18,514  persons  in  Costa  Rica 173 

Group  assembled  to  hear  lecture  and  receive  treatment  for  hook- 
worm disease,  Fusagasuga,  Colombia 177 

Exhibit  on  hookworm  disease  at  the  National  Agricultural  Exposi- 
tion, Brisbane,  Australia 177 

Negro  family,  residents  of  Federal  District,  Brazil 178 

Examining  board  and  other  apparatus  used  in  Jamaica  In  examining 

fecal  specimens  by  the  salt-flotation  process 178 

Number  of  persons  examined  and  treated  in  world-wide  campaign 

against  hookworm  disease,  1910-1921 181 

Sanitary  conditions  on  first  and  last  inspections  compared  for  the  five 
main  geographical  divisions  of  world-wide  campaign  against 

hookworm  disease,  1910-1921 182 

Ditch  before  and  after  draining,  Demopolis,  Alabama 189 

"V  "-shaped  ditch,  a  part  of  the  drainage  system  Installed  to  control 

malaria  in  and  near  La  Puebla-Rivas,  Nicaragua 189 

Antl-malaria,  impounding  water  experiment  at  Mound,  Louisiana. 

View  across  bayou,  700  yards  above  dam  site,  before  clearing.  .    190 

Same  as  Fig.  57,  showing  bayou  filled  with  water 190 

Quinine  treatment  of  malaria.  Sunflower  county,  Mississippi 195 

Proportionate  rates  of  sickness  from  malaria  and  other  diseases 

among  rural  population  of  seven  counties  in  Southeast  Missouri  198 


ILLUSTRATIONS  IX 

Effect  of  screening  and  construction  of  houses  on  incidence  of  malaria  199 

Yellow  fever  operations  in  Mexico  and  Central  America 201 

Tank  at  Colima,  Mexico,  from  which  are  distributed  the  small  fish 

placed  in  water  containers  at  the  homes 202 

Transporting  fish  from  landing  place  to  headquarters 202 

Growth  in  funds  for  county  health  work,  nine  southern  states. . . .  206 

Reduction  of  hookworm  infection  rates  in  ten  southern  states 207 

Deaths  from  typhoid  fever  in  nine  North  Carolina  counties 208 

Health  officer  vaccinating  children  in  rural  school  of  Mason  county, 

Kentucky 209 

Trachoma  clinic  at  Maysville,  Kentucky 209 

Class  of  midwives,  with  their  instructor 210 

Diphtheria  immunization,  Lenoir  county.  North  Carolina 210 

Control  of  typhoid  fever  in  Pearl  River  county,  Mississippi 213 

Graduates  and  students,  1921,  Training  School  for  Nurses,  Peking 

Union  Medical  College 255 

Medical-ward    building    and    pathology    building,    Peking    Union 

Medical  College 256 

General  plan  of  Peking  Union  Medical  College 264-265 

A  part  of  the  academic  procession  at  the  dedication  of  the  Peking 

Union  Medical  College,  September  19,  1921 269 

Graduate  students  attending  summer  course  in  roentgenology  at 

Peking  Union  Medical  College  in  1921 270 

Entrance  court,  Peking  Union  Medical  College 270 

Electrocardiograph  room  in  hospital,  Peking  Union  Medical  College  273 
An  operating  room  in  the  Peking  Union  Medical  College  Hospital.  .  273 
Laboratory  of  physiological  chemistry,  Peking  Union  Medical  College  274 
Dissecting  room,  anatomy  building,  Peking  Union  Medical  College  274 

Ward  in  Central  Hospital,  Peking 287 

Nursing  demonstration  and  practice  room.  Nurses'  Home,  Peking 

Union  Medical  College 287 

Corridor  connecting  units  of  the  hospital  group,  Peking  Union 

Medical  College 288 

Surgical  ward  of  hospital  building,  Peking  Union  Medical  College.  .   288 

Important  schools  of  medicine  in  the  Far  East 316 

Medical  schools  in  Japan 318 

Building  for  pathology  and  tropical  medicine.  Faculty  of  Medicine, 

Hong  Kong  University 321 

College  of  Medicine  and  Surgery,  University  of  the  Philippines    321 

Wing  of  General  Hospital,  Manila,  Philippine  Islands 322 

New  medical  building,  University  of  Alberta,  Canada 322 

The  new  medical  center  in  Brussels 329 

Institute  of  Anatomy,  University  College,  University  of  London. . .  329 
Fellows  from  eighteen  countries 330 


THE  ROCKEFELLER  FOUNDATION 

OFFICERS,  MEMBERS,  AND  COMMITTEES 
1921 

Members 

John  G.  Agar  **Starr  J.  Murphy 

Wallace  Buttrick  John  D.  Rockefeller 

Simon  Flexner  John  D.   Rockefeller,  Jr 

Raymond  B.  Fosdick  Wickliffe  Rose 

Frederick  T.  Gates  Julius  Rosenwald 

A.  Barton  Hepburn  Martin  A.  Ryerson 

*Charles  E.  Hughes  Frederick  Strauss 

Harry  Pratt  Judson  George  E.  Vincent 

Executive  Committee 

George  E.  Vincent,  Chairman 

Wallace  Buttrick  Wickliffe  Rose 

Raymond  B.  Fosdick  Frederick  Strauss 

Edwin  R.  Embree,  Secretary 

Finance  Committee 

John  D.  Rockefeller,  Jr.,  Chairman 

A.  Barton  Hepburn  Frederick  Strauss 

Chairman  of  the  Board  of  Trustees 
John  D.  Rockefeller,  Jr. 

President 
George  E.  Vincent 

General  Director  of  the  International  Health  Board 
Wickliffe  Rose 

General  Director  of  the  China  Medical  Board 
George  E.  Vincent 

General  Director  of  the  Division  of  Medical  Education 
Richard  M.  Pearce 

Secretary 
Edwin  R.  Embree 

Treasurer 
Louis  Guerineau  Myers 

Comptroller 
Robert  H.  Kirk 

Director  of  Information  Service 
Charles  C.  Williamson 


'Resigned  February  28,  1921 
♦Died  April  4,  1921. 


THE  ROCKEFELLER  FOUNDATION 

OFFICERS,  MEMBERS,  AND   COMMITTEES 
1922 

Members 

John  G.  Agar  Vernon  Kellogg 

Wallace  Buttrick  John  D.  Rockefeller 

John  W.  Davis  John  D.  Rockefeller,  Jr. 

Simon  Flexner  Wickliffe  Rose 

Raymond  B.  Fosdick  Julius  Rosenwald 

Frederick  T.  Gates  Martin  A.  Ryerson 

*A.  Barton  Hepburn  Frederick  Strauss 

Harry  Pratt  Judson  George  E.  Vincent 

Executive  Committee 
George  E.  Vincent,  Chairman 
Wallace  Buttrick  Vernon  Kellogg 

Raymond  B.  Fosdick  Wickliffe  Rose 

Edwin  R.  Embree,  Secretary 

Finance  Committee 

John  D.  Rockefeller,  Jr.,  Chairman 

Raymond  B.  Fosdick  Frederick  Strauss 

Chairman  of  the  Board  of  Trustees 
John  D.  Rockefeller,  Jr. 

President 
George  E,  Vincent 

General  Director  of  the  International  Health  Board 
Wickliffe  Rose 

Director  of  the  China  Medical  Board 
Roger  S.  Greene 

General  Director  of  the  Division  of  Medical  Education 
Richard  M.  Pearce 

Secretary 
Edwin  R.  Embree 

Treasurer 
Louis  Guerineau  Myers 

Comptroller 
Robert  H.  Kirk 

Office  Manager 
Frank  S.  Stale y 

Director  of  Information  Service 
Charles  C.  Williamson 


•  Died  January  as,  ipaa. 


THE  ROCKEFELLER  FOUNDATION 

President's    Review 


To  the  Members  of  the  Rockefeller  Foundation: 

Gentlemen : 

I  have  the  honor  to  transmit  herewith  a  gen- 
eral review  of  the  work  of  the  Rockefeller  Founda- 
tion for  the  period  January  1,  1921,  to  December 
31,  1921,  together  with  the  detailed  reports  of  the 
Secretary  and  the  Treasurer  of  the  Foundation, 
the  General  Director  of  the  International  Health 
Board,  the  Director  of  the  China  Medical  Board, 
and  the  General  Director  of  the  Division  of 
Medical  Education. 

Respectfully  yours, 

GEORGE  E.  VINCENT, 

President, 


Fig.  1. — Map  of  World-wide  Activities  of 

It  is  the  purpose  of  the  Rockefeller  Foundation  and  its  departmental 
boards  to  have  a  part  in  the  world-wide  movement  for  preventing  disease 
and  bringing  about  improved  conditions  of  health.  In  1921  aid  was 
extended  to  five  medical  schools  in  Canada,  to  one  in  England,  one  in 
Belgium,  one  in  Brazil,  and  one  in  the  United  States.  In  China  a  modern 
medical  school  in  Peking  was  supported  in  full  and  three  other  medical 
schools,  five  pre-medical  schools,  and  twenty-nine  hospitals  aided.  Two 
million  dollars  were  given  to  Harvard  for  a  school  of  public  health;  and 
the  School  of  Hygiene  and  Public  Health  at  Johns  Hopkins  University, 
and  courses  in  hygiene  at  Sao  Paulo,  Brazil,  supported.  A  campaign 
against  yellow  fever  was  continued  in  Mexico  and  Central  and  South 


PACIFIC 
OCEAN 


^■^W^-,"\ 


^  Medical  School  Supported  in  Full 
A   Medical  Schools  Aided 
^   Pre-medical  Schools  Aided 
X  Hospitals  Aided 

A  Emergency  Assistance  providing  Scientific  Equipment 
and  Medical  Journals 
'O  Food  Relief  Gift  to  American  Relief  Association 


7 


the  Rockefeller  Foundation 

America.  Aid  was  given  to  ten  southern  states  and  two  foreign  countries 
to  continue  the  work  of  malaria  control.  In  seventy-seven  counties  in 
sixteen  southern  states,  county  health  organization  on  a  full-time  basis 
was  promoted  in  co-operation  with  state  and  local  agencies.  Hookworm 
work,  now  merged  in  county  health  programs  in  the  Southern  States,  was 
prosecuted  abroad  in  eighteen  governmental  areas.  Anti-tuberculosis 
work  in  France  was  brought  close  to  the  point  of  complete  transfer  to 
French  agencies.  The  1920  gift  of  31,000,000  for  the  relief  of  European 
children  was  completed.  Emergency  assistance  in  the  form  of  scientific 
journals  and  apparatus  for  medical  schools  was  continued  in  five  countries 
and  extended  to  four  other  countries  in  Europe 


PRESIDENT'S  REVIEW 

The  Year  in  Brief 

During  the  year  1921  the  Rockefeller  Founda- 
tion (1)  continued  a  quarter-million  annual  ap- 
propriation to  the  School  of  Hygiene  and  Public 
Health  of  Johns  Hopkins  University,  (2)  pledged 
two  million  to  Harvard  for  a  school  of  health,  (3) 
contributed  to  public  health  training  in  Czecho- 
slovakia, Brazil,  and  the  United  States,  (4) 
aided  the  Pasteur  Institute  of  Paris  to  recruit 
and  train  personnel,  (S)  promoted  the  cause  of 
nurse  training  in  America  and  Europe,  (6)  under- 
wrote an  experimental  pay  clinic  in  the  Cornell 
Medical  School,  (7)  formally  opened  a  complete 
modern  medical  school  and  hospital  in  Peking, 
(8)  assisted  twenty-five  other  medical  centers  in 
China,  (9)  promised  a  million  dollars  for  the 
medical  school  of  Columbia  University,  (10) 
contracted  to  appropriate  three  and  one  half 
millions  for  the  rebuilding  and  reorganization  of 
the  medical  school  and  hospital  of  the  Free  Uni- 
versity of  Brussels,  (11)  made  surveys  of  medical 
schools  in  Japan,  China,  the  Philippines,  Indo- 
China,  Straits  Settlements,  Siam,  India,  Syria, 
and  Turkey,  (12)  supplied  American  and  British 
medical  journals  to  112  medical  libraries  on  the 
Continent,    (13)    supplemented    the    laboratory 


8        THE  ROCKEFELLER  FOUNDATION 

equipment  and  supplies  of  five  medical  schools  in 
Central  Europe,  (14)  defrayed  the  expenses  of 
commissions  from  Great  Britain,  Belgium,  Ser- 
bia, and  Brazil,  (IS)  provided  157  fellowships  in 
hygiene,  medicine,  physics  and  chemistry,  to 
representatives  of  eighteen  countries,  (16)  con- 
tinued a  campaign  against  yellow  fever  in 
Mexico,  Central  and  South  America,  (17)  prose- 
cuted demonstrations  in  the  control  of  malaria 
in  ten  states,  (18)  co-operated  in  hookworm  work 
in  nineteen  governmental  areas,  (19)  participated 
in  rural  health  demonstrations  in  seventy-seven 
American  counties  and  in  Brazil,  (20)  neared  the 
goal  of  transferring  to  French  agencies  an  anti- 
tuberculosis organization  in  France,  (21)  pro- 
vided experts  in  medical  education  and  public 
health  for  counsel  and  surveys  in  many  parts  of 
the  world,  and  rendered  sundry  minor  services  to 
governments  and  voluntary  societies.  These 
were  done  in  part  by  the  Foundation  directly, 
but  chiefly  through  its  departmental  agencies — 
the  International  Health  Board,  the  China  Medi- 
cal Board,  and  the  Division  of  Medical  Education. 

Telescope  and  Microscope 

"Cure  looks  through  the  microscope,  preven- 
tion through  the  telescope"  is  the  clever  phrasing 
of  a  successful  American  health  officer.  If  the 
figure  is  not  too  closely  examined  it  serves  its 


PRESIDENT  S    REVIEW  9 

purpose.  There  has  been  and  still  is  a  marked 
difference  between  the  average  physician's  point 
of  view  and  the  sanitarian's.  The  former  deals 
with  disease  which  has  manifested  itself;  the 
latter  seeks  to  foresee  and  to  forestall  its  oc- 
currence. The  one  thinks  of  the  individual 
patient,  the  other  of  the  community  as  a 
whole. 

It  is  sometimes  cynically  asserted  not  only 
that  the  attitudes  of  the  two  differ,  but  that  their 
interests  clash.  In  a  town  from  which  malaria 
had  been  banished,  a  local  doctor  who  had  al- 
most specialized  in  chills  and  fever  was  asked 
how  his  profession  had  been  affected.  "If  it 
hadn't  been  for  the  influenza  we'd  have  gone 
broke;  that  saved  us,"  was  the  half-jocular  reply. 
If  the  two  things  are  looked  at  narrowly,  locally, 
and  for  a  brief  period,  there  is  undoubtedly  a 
conflict  of  interests. 

But  the  leaders  of  the  medical  profession  have 
not  taken  the  myopic  view.  As  a  matter  of  fact 
they  have  been  the  very  prophets  and  promoters 
of  preventive  medicine.  The  men  who  have 
done  most  to  introduce  the  telescope  have,  with 
certain  notable  exceptions,  been  trained  prima- 
rily to  concentrate  upon  the  microscope.  With 
them  cure  and  prevention  have  been  not  sharply 
contrasted  but  closely  related  ideas.  They  have 
increasingly  regarded  experience  with  disease  in 


lO       THE  ROCKEFELLER  FOUNDATION 

individuals  as  a  means  of  protecting  the  com- 
munity against  it. 

The  progress  of  public  health  depends  upon  the 
appreciation,  sympathy,  and  support  of  the 
medical  profession.  Doctors  will  gradually  come 
to  think  of  themselves  and  to  be  regarded  by 
the  public  as  primarily  responsible  for  keeping 
people  well.  Periodic  physical  examinations, 
the  early  discovery  of  incipient  maladies,  warn- 
ings against  environmental  dangers,  the  wise 
control  of  diet,  insistence  on  appropriate  exer- 
cise, suggestions  about  personal  and  social  life, 
will  in  increasing  measure  replace  medicines, 
hospitals,  and  sanatoria;  may  even  reduce  the 
demand  for  surgical  service.  Who  knows  but 
that  the  doctor  of  the  future,  receiving  an  annual 
retaining  fee  from  his  clients,  will  feel  no  em- 
barrassment in  taking  the  initiative  and  in  keep- 
ing a  watchful  eye  upon  them?  Then  a  case  of 
illness  would  be  not  the  physician's  opportunity 
but  a  reflection  upon  his  vigilance. 

Progress  in  Prevention 

Jenner's  discovery  of  vaccination  for  smallpox, 
Pasteur's  researches  in  the  causation  of  various 
diseases  by  bacteria  and  microbes,  the  use  of 
vaccines  and  sera.  Lister's  introduction  of 
antiseptic  surgery,  are  striking  illustrations  of  the 
scientific  knowledge  of  the  origin,  spread,  and 


t>RESIDENT*S   REVIEW  II 

prevention  of  certain  maladies  which  has  been 
made  available  since  the  end  of  the  eighteenth 
century,  and  especially  during  the  last  fifty  years. 
Today  hundreds  of  trained  investigators  in  many 
countries  are  verifying,  revising,  and  adding  to 
this  body  of  truth  upon  which  all  progress  in 
preventive  medicine  depends. 

The  application  of  part  of  this  knowledge  by 
men  of  imagination  and  organizing  ability  has 
been  a  boon  to  mankind.  The  presence  of 
smallpox  is  now  a  disgrace  to  any  civilized  com- 
munity or  country;  cholera  and  plague  have  dis- 
appeared from  the  leading  nations;  typhoid  fever 
has  been  enormously  reduced;  malaria  and  hook- 
worm disease  are  giving  ground;  yellow  fever  is 
being  narrowly  restricted;  typhus  is  practically 
unknown  among  a  cleanly  people;  the  fear  of 
diphtheria  has  been  largely  allayed.  Such  vic- 
tories as  these,  together  with  advances  in  general 
sanitation,  higher  living  standards,  more  atten- 
tion to  individual  health  habits,  have  resulted  in 
steadily  falling  death  rates  in  all  the  more  pro- 
gressive countries. 

But  it  is  too  early  to  feel  complacent.  Only  a 
beginning  has  been  made.  Many  diseases  still 
baffle  the  health  authorities.  Whole  regions 
have  been  almost  untouched.  Even  the  most 
advanced  communities  fall  far  short  of  what 
might  be  attained.     The  average  individual  re- 


14       THE  ROCKEFELLER  FOUNDATION 

mains  relatively  ignorant  and  negligent  of  sani- 
tary science  and  of  personal  hygiene.  Almost 
all  physicians  are  still  too  exclusively  concerned 
with  the  individual  aspect  of  disease. 

Stages  in  the  progress  of  preventive  medicine 
are  distinguishable.  First  comes  control  of  the 
physical  environment  through  pure  water,  milk, 
and  food  supplies,  adequate  sewerage  and  refuse 
disposal  systems,  improved  housing,  heating,  and 
ventilation.  Then  follows  control  of  diseases 
other  than  those  whose  causes  are  water  and 
food  borne.  Various  forms  of  occupational 
hazards  and  maladies  are  also  attacked.  Con- 
cern for  the  welfare  of  mother  and  child  is  a 
prominent  feature  at  this  stage.  The  third 
stage  emphasizes  the  vital  part  which  personal 
hygiene  plays.  It  is  roughly  estimated  that  80 
per  cent  of  the  maladies  which  produce  the  total 
death  rate  cannot  be  directly  controlled  by  the 
sanitarian.  He  must  persuade  individuals  to 
conform  to  the  laws  of  health  and  to  report 
promptly  the  first  sign  that  anything  is  amiss. 

A  fourth  phase  just  beginning  to  emerge  has  to 
do  with  economic,  social,  and  mental  influences. 
Income,  standard  of  living,  opportunities  for 
social  intercourse  and  recreation,  all  have  im- 
portant relations  to  individual  and  community 
health.  Mental  hygiene,  which  is  coming  to  be 
recognized  as  a  part  of  public  health,  deals  with 


PRESIDENT  S    REVIEW  1 3 

problems  of  defects  and  delinquency  in  children 
and  criminality  in  adults,  with  nervous  and 
mental  disorders,  with  the  classification,  treat- 
ment, and  custodial  care  of  the  feeble-minded  and 
insane,  and  related  questions.  To  the  support  of 
the  work  of  the  National  Committee  for  Mental 
Pygiene  the  Rockefeller  Foundation  contributed 
during  1921,  ?86,370.S7. 

Changing  Ideals  of  Health 

Advances  in  the  cure  and  prevention  of  disease 
reflect  a  shifting  of  emphasis  and  a  gradual  revi- 
sion of  the  idea  of  health  itself.  Being  "up  and 
around"  or  "I  can't  complain"  represents  a  far 
from  stimulating  conception  of  bodily  prosperity, 
yet  a  *' vertical  rather  than  a  horizontal  position" 
is  one  criterion.  Freedom  from  conscious  pain 
would  seem  to  be  almost  the  obvious  starting 
point  for  any  useful  standard  of  health,  yet  even 
this  may  be  misleading.  Conformity  with  ob- 
jective norms  such  as  average  temperature, 
height,  weight,  blood  pressure,  condition  of 
various  organs,  results  of  blood  and  other  analy- 
ses, represents  a  more  trustworthy  basis  of 
valuation.  But  after  all  these  are  at  best  nega- 
tive or  neutral  ideals.  There  is  a  growing  de- 
mand for  a  positive  conception  which  in  the 
individual  registers  itself  in  a  keen  sense  of  physi- 
cal and  mental  vigor,  a  joy  of  living. 


14       THE  ROCKEFELLER  FOUNDATION 

There  is  a  tendency  in  certain  quarters  to  ex- 
tend the  meaning  of  preventive  medicine  from 
merely  negative  measures  to  include  more  posi- 
tive and  constructive  ideals  of  community  or 
national  health.  Sanitation,  control  of  conta- 
gion, protection  against  many  other  menaces, 
have  become  in  advanced  countries  accepted 
procedures.  Attention  is  now  directed  to  more 
positive  things,  education  of  the  public  in  per- 
sonal hygiene,  nutrition  for  young  and  old, 
physical  exercise  and  mass  athletics,  provision 
for  mental  and  emotional  satisfactions  through 
social  and  recreational  activities. 

On  the  other  hand,  probably  the  great  majority 
of  public  health  officers  who  are  engaged  in 
practical  field  work  are  rather  dubious  about 
giving,  at  least  for  some  time  to  come,  so  broad  a 
meaning  to  the  idea  of  preventive  medicine. 
They  feel  that  so  much  remains  to  be  done  on  the 
negative  side  that  anything  which  may  withdraw 
public  attention  from  sanitation,  control  of 
contagious  diseases,  infant  welfare,  medical  in- 
spection of  school  children,  and  a  somewhat 
narrower  conception  of  personal  hygiene,  may  for 
the  present  do  harm  rather  than  good.  But  this 
reluctance  represents  a  demand  for  practical  ef- 
ficiency, not  a  failure  to  realize  that  with  the 
progress  of  knowledge  the  idea  of  health  is  being 
reinterpreted  in  fuller  and  more  positive  terrnSt 


PRESIDENT  S    REVIEW 


15 


The  Demand  for  Trained  Leadership 

Even  a  hasty  glance  at  the  gains  which  have 
been  made  in  safeguarding  human  Uves  makes 
one  reaUze  how  much  scientific  knowledge,  spe- 
cialized skill, 
and  organized 
capacity  have 
been  called  into 
service.  The 
expanding  idea  J'////////// 
of  health  is  add- 
ing new  types  ^^^^^^^^^ 
of     technically        \Mf0//         '   '  ^ 

expert      indi-  n^^%^^^W//i?^x»5v'^43 

viduals  to   the  ^^^^^lUlI/////, 

personnel      of    Fig.  2. — Full-time  Health  Workers  in 

health      work.  United  States   1921 

Numher  Per  cent 
The  list  now  in-     l-  Officers  of  the  United  States 

Public  Health  Service...       200         1.9 
eludes:    OincerS     2.  Principal    executives    em- 
,      ,  .    -.         ,  ployed  by  states,  cities, 

and   chiefs  who  and  counties 470         4.5 

1     3.  Subordinate  executives  ...       500         4.8 
are    m     general     4_  Laboratory  workers,  public 

rViarcr^        c'jni'  health  laboratories 1,200       11.6 

Cnarge,      Sani-     5^  piu^bing,  sanitary,  dairy, 

tary  engineers,    .     and  food  inspectors 3,000     28.9 

•^  o  '6.  Public   health   nurses   em- 

laboratory      di-  ployed  by  public  agencies    5,000       48.2 

rectors  who  deal  with  bacteria,  microbes,  animal 
parasites,  et  cetera,  and  prepare  vaccines  and  sera, 
specialists  in  statistics  of  births,  sickness,  and 
deaths,  field  experts  in  the  control  of  epidemics, 


1 6       THE  ROCKEFELLER  FOUNDATION 

administrators  of  clinics,  hygienists  for  infants, 
medical  inspectors  of  school  children,  mental 
hygienists  and  psychologists,  leaders  in  health 
education  for  schools  and  the  general  public, 
visiting  nurses,  laboratory  technicians,  food  and 
sanitary  inspectors. 

In  the  United  States  there  are  at  present  about 
10,000  persons  engaged  in  public  health  work 
under  Federal,  state,  and  municipal  or  county 
auspices.  In  Great  Britain  probably  an  equal 
number  are  giving  all  their  time  to  the  work  of 
preventive  medicine.  The  number  in  the  service 
of  non-governmental  agencies  of  all  kinds  can 
scarcely  be  estimated  but  may  represent  nearly 
as  many  more.  The  self-governing  Dominions 
employ  a  considerable  number  of  professional 
sanitarians.  In  Continental  Europe  health  or- 
ganization has  not  as  a  rule  reached  so  high  a 
degree  of  development  as  in  the  British  Isles. 
In  many  tropical  countries,  e.g.,  India,  Java,  the 
Philippines,  both  curative  and  preventive  medi- 
cine are  administered  by  corps  of  trained  govern- 
ment officials.  In  all  parts  of  the  world  there  is 
an  increasing  demand  for  men  and  women 
competent  to  do  different  kinds  of  public  health 
work.  A  forecast  of  the  probable  number  needed 
during  the  next  ten  years  in  the  United  States 
calls  for  20,000  persons. 

Only  in  the  last  few  years  have  opportunities 


PRESIDENT  S   REVIEW 


17 


for  special  public  health  training  been  available 
in  the  United  States.  With  exceptions  al- 
most negligible  in  number,  American  health 
officers  have 
had  no  other 
formal  train- 
ing than  that 
of  doctors  of 
curative  medi- 
cine. They 
have  gained 
what  special 
competence 
they  may  pos- 
sess  in  the 
hard,  waste- 
ful, and  one- 
sided School 
of  Experience. 
That  a  few 
have  attained 
the  level  of 
"sanitary 
statesmen"  is 
an  evidence  of 
exceptional  ability  and  character,  not  a  vindica- 
tion of  rule-of-thumb,  trial-and-error  methods. 
The  future  of  preventive  medicine  depends  upon 
drawing   first-class    men   and   women   into   the 


Fig.  3. — Professional  Training  of 

Heahh  Officials 

This  chart  is  based  on  a  study  of  the  profes- 
sional training  of  the  responsible  heads  of  health 
departments  in  seventy-two  municipalities  and 
forty-eight  states.  Less  than  11  per  cent  of  those 
filling  these  important  positions  have  had  special 
preparation  for  their  work 

Number  Per  cent 

1.  Physicians  without  public 

health  training 101 

2.  Physicians     with     public 

health  training 10 

3.  Laymen    without    profes- 

sional training 6 

4.  Engineers      with      public 

health  training 3 


84.2 
8.3 
5.0 
2.5 


1 8       THE  ROCKEFELLER  FOUNDATION 

profession  and  giving  them  efficient,  modern, 
specialized  training  and  supervised  practical 
experience. 

Handicaps  to  Recruiting 

It  is  not  to  be  denied  that  on  the  whole  the 
best  ability  has  been  drafted  into  the  service  of 
curative  rather  than  of  preventive  medicine. 
More  than  four  hundred  replies  to  questions 
recently  put  to  students  now  enrolled  in  leading 
American  medical  schools  disclose  an  attitude  of 
ignorance,  indifference,  even  antipathy  with  re- 
spect to  a  career  in  public  health  work.  The 
reasons  these  young  men  give  either  for  not  con- 
sidering at  all  or  for  deciding  against  such  a  life 
work  are:  (1)  it  is  not  a  socially  recognized, 
clearly  professionalized  calling;  (2)  there  are  no 
special  schools  for  adequate  training;  (3)  tenure 
and  promotion  depend  not  on  merit  but  political 
"pull";  (4)  salaries  are  meager;  (5)  the  private 
practice  of  curative  medicine  is  more  reputable, 
independent,  profitable,  and  satisfying. 

These  young  men  are  in  many  respects  unin- 
formed and  misinformed.  Preventive  medicine 
has  already  gained  the  status  of  a  profession  and 
is  making  rapid  progress  in  public  favor.  At 
least  two  special  schools  of  high  rank  are  offering 
a  thorough  and  appropriate  training.  An  in- 
creasing number  of  important  posts  are  freeing 


president's  review  tgl 

themselves  from  the  trammels  of  "  spoils  politics." 
The  salary  received  by  a  health  officer  of  full 
rank  probably  exceeds  the  income  of  the  average 
private  practitioner.  Private  practice  has  many 
disadvantages:  excessive  overtime  and  night 
work,  poor  collections,  the  necessity  of  dunning 
patients,  little  chance  to  study,  constant  eco- 
nomic pressure,  a  heavy  burden  of  unpaid  service, 
competition  with  quacks  and  charlatans,  tempta- 
tion to  surrender  scientific  ideals.  Public  health 
service,  on  the  other  hand,  is  making  a  strong 
appeal  to  many  men  and  women  of  imagination, 
courage,  and  social  spirit  just  because  it  does  not 
involve  most  of  these  things  and  offers  many 
positive  attractions. 

Yet  it  must  be  admitted  that  the  sceptical 
undergraduates  are  not  wholly  wrong.  Public 
ignorance  and  indifference,  invidious  compari- 
sons, lack  of  sound  training  in  many  officials, 
prejudice  against  law  enforcement,  delay  the  full 
appreciation  of  what  preventive  medicine  means 
to  society.  The  establishment  of  adequate 
schools  has  been  a  recent  event.  A  few  dis- 
heartening instances  of  political  tampering  with 
health  departments  have  occurred  of  late.  It  is 
also  true  that  the  level  of  pay  is  far  too  low. 
Even  the  few  highest  salaries  suffer  painfully  in 
comparison  with  the  annual  incomes  of  leading 
private   consultants    and    surgeons.     A   greater 


20       THE  ROCKEFELLER  FOUNDATION 

share  of  popular  admiration,  larger  freedom  from 
control,  close  personal  relations  with  apprecia- 
tive individuals,  a  deeper  sense  of  professional 
pride,  probably  are  still  the  portion  of  the 
practitioner  of  curative  medicine.  Persistent 
efforts,  then,  will  be  needed  to  make  public  health 
careers  more  attractive  to  the  persons  best  fitted 
for  successful  work.  Much  can  be  done  to  en- 
lighten and  challenge  medical  students  and  young 
graduate  doctors,  but  the  problem  calls  for  some- 
thing far  more  fundamental  than  that. 

The  Responsibility  of  the  Public 

The  cry  is  frequently  heard  that  this  govern- 
mental service  or  that  "must  be  taken  out  of 
politics."  In  one  sense  this  is  absolutely  es- 
sential to  efficiency.  A  public  function  which 
calls  for  technical  expertness  is  hopelessly  handi- 
capped if  it  be  treated  as  the  spoils  of  a  political 
boss  or  of  a  victorious  party  machine.  To  no 
public  service  does  this  apply  more  strikingly 
than  to  a  department  of  health.  The  moment 
efforts  are  made  to  influence  appointments,  pro- 
motions, salaries,  policies,  law  enforcement,  by 
political  pressure  for  individual  or  party  ends  the 
demoralization  of  the  work  begins.  The  degree 
to  which  such  things  are  possible  is  an  index  of 
the  intelligence,  spirit,  and  character  of  any  com- 
munity. 


president's  review  21 


Yet  in  another,  the  original,  meaning  of  politics 
public  health  ought  to  be  always  in  politics. 
The  safeguarding  of  the  health  of  the  people  is 
a  community  task  and  responsibility.  It  is  a 
proper  and  important  subject  for  public  atten- 
tion and  discussion.  Ofhclals  are  In  duty  bound 
to  present  their  programs  and  budgets  to 
boards,  councils,  and  the  public  and  to  give 
convincing  reasons  for  the  measures  and  expen- 
ditures that  are  proposed.  One  of  the  essential 
qualifications  of  a  successful  health  officer  is  the 
ability  to  explain  his  policies  so  as  to  win  support 
for  them.  The  hookworm  campaigns  of  the  Inter- 
national Health  Board,  for  example,  are  always 
preceded  by  systematic  education  of  the  com- 
munity In  the  cause,  effects,  cure,  and  prevention 
of  the  disease.  Only  when  people  understand 
the  purpose  and  methods  of  public  health  meas- 
ures can  they  be  counted  upon  to  co-operate 
willingly  and  effectively. 

But  obviously  the  busy  health  officer  and  his 
assistants  cannot  assume  sole  or  even  the  chief 
responsibility  for  creating  and  maintaining  the 
popular  understanding  and  backing  essential  to 
the  success  of  modern  and  progressive  health 
policies.  Elected  officials,  public-spirited  pri- 
vate citizens,  the  schools,  public  and  private,  the 
press,  chambers  of  commerce,  women's  clubs, 
social  agencies,  voluntary  health  associations  are 


22        THE  ROCKEFELLER  FOUNDATION 

the  organs  by  which  counties,  towns,  cities,  and 
states  should  be  kept  constantly  conscious  of 
health  measures  until  these  have  become  a  part 
of  the  accepted  and  well-administered  routine 
of  daily  life.  Then  vigilance  becomes  the  price 
of  safeguarding  what  has  been  achieved  and  the 
means  of  supporting  new  plans  for  further  ad- 
vance. In  the  long  run  under  representative 
government  a  community  will  get  the  kind  of 
health  administration  that  it  deserves. 

Until  recently  there  has  been  little  or  no  co- 
operation among  the  scores  of  voluntary  health 
societies  in  the  United  States  which  are  seeking  to 
educate  the  public  and  to  promote  various  health 
measures.  The  result  has  been  a  good  deal  of 
duplication,  some  working  at  cross  purposes,  a 
certain  confusion  in  the  public  mind.  It  is 
encouraging  to  note  that  ten  of  the  largest  and 
most  influential  of  these  societies  have  formed  a 
National  Health  Council,  taken  offices  in  the 
same  building,  and  are  working  out  plans  for 
better  team-work.  During  1921  the  Rockefeller 
Foundation  contributed  nearly  twenty  thousand 
dollars  to  the  budget  of  this  central  bureau. 

A  West  Point  of  Hygiene  at  Johns  Hopkins 

The  International  Health  Board  realized  early 
in  its  history  that  a  chief  problem  in  disease  pre- 
vention would  be  to  find  men  qualified  both 


president's  review  23 

scientifically  and  practically  to  do  the  work. 
An  ordinary  medical  school  education  is  not 
enough.  There  must  be  special  training  in  the 
scientific  principles,  the  administrative  methods, 
and  the  point  of  view  of  preventive  medicine  and 
public  health.  So  the  Board  decided  to  estab- 
lish a  school  of  health  under  the  auspices  of  a 
university  and  in  close  relations  with  a  modern 
medical  school,  but  at  the  same  time  a  separate 
institution  with  its  own  buildings  and  equipment, 
its  own  teaching  staff,  its  own  professional  aims, 
its  own  esprit  de  corps.  After  a  study  of  the 
various  possibilities  it  was  decided  in  1916  to  ask 
Johns  Hopkins  University  to  assume  responsi- 
bility for  establishing  a  School  of  Hygiene  and 
Public  Health  for  which  the  Rockefeller  Founda- 
tion undertook  to  supply  such  sums  as  might  be 
agreed  upon  as  necessary  for  buildings,  equip- 
ment, and  annual  maintenance. 

In  1918  the  new  school,  housed  in  temporary 
quarters,  and  equipped  and  manned,  opened  its 
doors.  Courses  of  study  leading  to  the  degrees 
of  Doctor  of  Public  Health,  Doctor  of  Science  in 
Hygiene,  Bachelor  of  Science  in  Hygiene,  and  to 
the  Certificate  in  Public  Health,  were  offered. 
Brief,  intensive  courses  for  active  health  officers 
were  announced,  and  opportunities  were  prom- 
ised to  other  types  of  special  students.  For  the 
academic  year  1920-1921  the  faculty  numbered 


24       THE  ROCKEFELLER  FOUNDATION 

forty;  122  students  were  registered,  of  whom 
fifty-six  were  candidates  for  degrees  or  a  certif- 
icate. The  special  six  weeks'  course  for  health 
officers  enrolled  twenty-nine  students.  The 
health  departments  of  six  states  and  of  Costa 
Rica  and  Porto  Rico  were  represented.  A  brief 
course  for  a  group  from  the  field  staflf  of  the 
International  Health  Board  was  also  provided. 
In  addition  to  the  regular  courses  twenty-one 
public  lectures  on  selected  topics  in  hygiene  and 
preventive  medicine  were  given  by  prominent 
specialists. 

The  school  has  three  leading  aims :  to  provide  a 
fundamental  scientific  training,  to  afford  practi- 
cal field  experience  under  competent  supervision, 
and  to  add  to  the  knowledge  of  hygiene.  The 
laboratory  and  lecture  courses  deal  with:  (1) 
the  micro-organisms  which  are  the  inciting  causes 
of  disease,  (2)  the  study  of  resistance  and  im- 
munity, and  the  preparation  of  vaccines  to  pro- 
tect against  certain  infections  and  of  sera  to 
mitigate  their  virulence,  (3)  the  primitive  animal 
parasites,  for  example,  the  blood  parasite  which 
causes  malaria,  the  ameba  of  dysentery,  (4)  the 
parasitic  worms  of  many  kinds,  of  which  the 
hookworm  is  the  best  known,  (5)  the  insects  by 
which  diseases  are  communicated,  such  as  the 
mosquitoes  that  spread  malaria  and  yellow  fever, 
(6)  the  collection,  arrangement,  and  interpret^- 


Fig.  4. — Students  at  work  in  the  bacteriological  labora- 
tory of  the  School  of  Hygiene  and  Public  Health  of  Johns 
Hopkins  University 


1 

Ii|  f 

Fig.  5. — Class  in  protozoology,  Johns  Hopkins  School  of 
Hygiene  and  Public  Health 


fmwmmwsmmiimmmm 

1 0  fin  m  m  m  m  m  m  m  m  m  do  an  qd  d 
D  nn  m  m  m  m  m  m  m  on  nn  an  no  no  n 
0  ffi  IB  on  00  00  on  on  nn  no  on  no  on  no  u 


a  illlDBGQD  s 


Fig.  6. — Architect's  drawing  of  proposed  new  building 
to  house  the  School  of  Hygiene  and  Public  Health  of  Johns 
Hopkins  University 


Fig.  7. — ^The  "  Pay  Clinic"  of  Cornell  University  Medical 
College.  The  picture  shows  the  main  entrance  hall  of  the 
clinic,  where  new  patients  are  admitted  and  directed  to  the 
various  departments  after  the  necessary  general  informa- 
tion has  been  secured,  appointments  made,  and  fees  paid. 
Close  co-operation  of  a  group  of  specialists  in  all  the  leading 
branches  of  medicine  makes  possible  careful  diagnosis  and 
thorough  treatment  at  an  expense  which  patients  of 
moderate  means  can  afford 


iPRESIDENX's    REVIEW  ±'J 

tlon  of  statistics  about  births,  deaths,  sickness, 
et  cetera,  (7)  the  methods  of  controlling  infectious 
diseases,  especially  epidemics  of  various  commu- 
nicable diseases,  (8)  the  problems  of  water  sup- 
ply, sewerage,  disposal  of  refuse,  housing,  ventila- 
tion, (9)  the  functions  of  the  human  body  in 
relation  to  health,  (10)  the  chemical  aspects  of 
hygiene,  (11)  the  significance,  for  preventive 
medicine,  of  mental  and  nervous  diseases,  delin- 
quency, crime,  feeble-mindedness,  and  insanity, 
(12)  the  principles  of  nutrition  and  diet,  (13)  the 
legal  aspects  of  sanitation  and  hygiene,  (14)  the 
rules  of  health  for  the  individual,  (IS)  maternity 
and  child  hygiene,  and  (16)  the  organization  and 
administration  of  public  health  work. 

Actual  experience  in  the  field  is  gained  by 
visits  to  various  centers  of  sanitary  and  health 
activity  and  by  volunteer  service  in  the  Balti- 
more Department  of  Health,  or  under  the  Mary- 
land State  Board,  or  in  connection  with  the 
United  States  Public  Health  Service.  Summer 
vacation  employment  with  state  or  municipal 
health  boards  or  other  agencies  provides  valu- 
able first-hand  contact  with  problems  of  hygiene 
and  administration.  With  increasing  numbers 
of  students,  the  difiiculties  of  finding  enough  ap- 
prentice posts  and  of  making  sure  of  educative 
supervision  will  be  serious.  Plans  are  already 
under  way  to  establish  a  special  training  area,  a 


28       THE  ROCKEFELLER  FOUNDATION 

field  laboratory.  Washington  county,  Mary- 
land, with  a  population  of  60,000  almost  equally 
divided  between  city  and  country,  has  been 
selected  for  this  purpose.  The  county  health 
unit  will  include:  a  director,  a  sanitary  inspector, 
a  laboratory  technician,  a  clerk,  an  attendant, 
and  three  nurses.  A  permanent  headquarters,  a 
laboratory,  and  motor  cars  will  be  provided.  A 
sanitary  and  contagious  disease  survey  will  be 
made  and  an  organization  for  dealing  with  the 
conditions  will  be  created.  This  plan  will  furnish 
opportunities  for  training  students  and  for  test- 
ing methods.  The  project  is  jointly  supported 
by  the  Maryland  State  Board  of  Health,  local 
community  and  county  organizations,  the  United 
States  Public  Health  Service,  the  International 
Health  Board,  and  the  School  of  Hygiene  and 
PubUc  Health. 

The  investigative  work  of  the  School  has 
covered  a  wide  range  of  problems.  A  volume 
of  scientific  contributions  made  by  members  of 
the  staff  and  published  during  the  year  contained 
fifty-five  papers.  The  American  Journal  of  Hy- 
giene, of  which  several  numbers  have  appeared, 
is  published  under  the  auspices  of  the  School. 
It  will  confine  its  articles  largely  to  results  of  re- 
search in  the  laboratory  and  the  field.  An  active 
society  of  hygiene  has  been  established.  The 
chief  field  research  activities  of  this  period  in- 


PRESIDENT  S    REVIEW  29 

elude:  an  investigation  of  the  diphtheria  situation 
in  Baltimore,  a  special  study  in  Trinidad  of 
hookworm  eggs  and  larvae  in  the  soil,  demonstra- 
tions in  the  feeding  of  undernourished  children, 
a  co-operative  survey  of  health  conditions  among 
the  school  children  of  Baltimore.  In  the  last 
investigations  6,000  children  were  weighed  and 
measured;  1,500  were  given  medical  examina- 
tions. The  results  showed  that  between  20  and 
30  per  cent  of  the  children  were  10  per  cent  or 
more  under  the  normal  weight  for  their  ages. 
Much  the  same  situation  had  been  found  in  New 
York  and  other  eastern  cities  of  the  United  States. 
For  the  current  support  of  the  School  in  1921 
the  Foundation  contributed  3250,000.  It  has 
also  promised  to  give  money  for  a  new  building 
and  for  additional  equipment.  This  building, 
which  will  be  close  to  the  Medical  School  and 
Hospital,  will  contain  laboratories,  lecture  rooms, 
a  library,  a  museum,  an  auditorium,  and  will  be 
provided  with  all  the  essential  apparatus  and 
other  equipment  for  instruction  and  investiga- 
tion. 

Harvard  Expands  its  Health  Course  into  a  School 

Harvard  was  the  second  American  university 
to  establish  a  course  in  public  health  training. 
The  University  of  Pennsylvania  was  the  pioneer. 
By  joining  forces  with  the  Massachusetts  Insti- 


30       THE  ROCKEFELLER  FOUNDATION 

tute  of  Technology,  Harvard  was  able  to  offer  a 
fairly  well-rounded  curriculum  of  fundamental 
studies  in  preventive  medicine  and  sanitary 
engineering.  Tropical  medicine  was  also  given 
an  important  position  which  has  been  well  main- 
tained. From  the  outset  stress  was  laid  upon 
work  in  the  field.  Every  candidate  for  a  degree 
was  required  to  make  a  sanitary  or  health  survey 
in  a  community  near  Boston.  Fortunately  a 
good  many  towns  and  smaller  cities  with  credit- 
able health  departments  were  easily  accessible. 
Graduates  of  the  Harvard-Technology  course 
gained  useful  practical  experience.  They  were 
successful  in  securing  posts  in  health  departments 
and  in  other  services. 

More  recently  Harvard,  through  its  medical 
school,  took  the  lead  in  establishing  courses  of 
training  in  the  field  of  industrial  hygiene,  which 
deals  with  the  problems  of  fatigue,  occupational 
disease,  sanitation  of  mines  and  industrial  plants, 
physical  and  medical  examination  and  care  for 
transportation,  factory,  and  commercial  work- 
ers, education  in  personal  hygiene,  mass  athletics, 
recreation,  et  cetera.  The  co-operation  and  finan- 
cial support  of  manufacturing  and  retail  establish- 
ments in  and  near  Boston  were  secured.  A  num- 
ber of  investigations  were  made  to  determine  the 
causes  and  to  discover  ways  of  preventing  or 
minimizing  certain  maladies  which  are  traceable 


PRESIDENT  S   REVIEW  3 1 

to  industrial  processes.  Students  enjoyed  op- 
portunities for  concrete  experience  in  connection 
with  the  sanitation  and  hygienic  administration 
of  factories  and  large  department  stores.  An 
important  publication,  The  Journal  of  Industrial 
Hygiene,  has  been  established  under  the  auspices 
of  this  division  of  the  Harvard  Medical  School. 
Admirable  as  the  work  in  public  health  training 
with  its  later  emphasis  on  industrial  hygiene  was, 
the  Harvard  authorities  were  not  satisfied. 
They  felt  the  need  of  adding  departments  which 
were  lacking — for  example,  public  health  ad- 
ministration and  epidemiology  and  vital  statis- 
tics— and  of  strengthening  other  courses  which 
were  undermanned,  inadequately  equipped,  and 
too  meagerly  supported.  There  was  a  desire  to 
reorganize  and  unify  the  whole  undertaking  into 
a  separate  school  of  health  which  should  have  its 
own  headquarters  and  teaching  staff.  It  was 
estimated  that  to  accomplish  this  and  to  provide 
for  future  growth  additional  funds  to  the  amount 
of  33,000,000  would  be  required.  Toward  this 
the  Rockefeller  Foundation  appropriated  31,660,- 
000,  and  agreed  if  certain  contingencies  should 
arise  during  the  next  five  years  to  supply  3500,000 
more.  The  remainder  of  the  total  sum  required 
was  set  aside  or  pledged  by  Harvard,  and  the 
organization  of  the  new  institution  is  well  under 
way. 


32        THE  ROCKEFELLER  FOUNDATION 

The  Harvard  School  will  be  fortunate  in  having 
within  easy  access  numerous  urban  and  rural 
health  departments,  city  and  state  laboratories, 
a  large  hospital  for  contagious  diseases,  industrial 
and  other  clinics,  factory  and  store  health  sys- 
tems, the  port  quarantine  stations,  the  Carnegie 
Nutrition  Laboratories,  and  many  voluntary 
health  associations  with  their  clinics  and  nurses. 
All  these  institutions  and  agencies  will  afford 
most  valuable  experience  for  students  and  op- 
portunities for  fruitful  investigations.  While 
the  Harvard  School  will  include  all  the  funda- 
mental subjects  it  will  not  in  every  respect  dupli- 
cate the  work  at  Johns  Hopkins.  There  will  be 
differences  in  specialization  and  emphasis,  so 
that  the  two  institutions  together  will  enrich  and 
widen  the  field  of  investigation  and  extend  the 
facilities  for  training.  Advanced  students  may 
well  study  both  in  Boston  and  in  Baltimore. 

Health  Training  at  Home  and  Abroad 

New  York  University  has  recently  completed 
a  building  a  large  part  of  which  is  to  be  rented  as 
a  branch  laboratory  of  the  New  York  State  De- 
partment of  Health.  The  University  authorities 
were  anxious  to  add  to  the  building  another  floor 
which  should  house  a  clinic  for  the  teaching  of 
personal,  infant,  school,  and  industrial  hygiene. 
The    plan    also    included    the    remodeling    and 


I>RESIDENT*S    REVIEW  ^ 

equipping  of  a  neighboring  building  as  a  museum 
to  display  models  and  other  exhibits  in  sanitation, 
ventilation,  industrial  hygiene,  and  housing. 
For  the  carrying  out  of  this  project  the  Rocke- 
feller Foundation  contributed  ^3 5,000. 

One  essential  kind  of  training  takes  the  form 
already  mentioned  of  special  intensive  courses 
for  persons  who  are  actually  engaged  in  health 
work.  State  departments  of  health  and  the 
United  States  Public  Health  Service  are  conduct- 
ing institutes  to  meet  this  need.  In  several 
cases  the  Foundation  through  the  International 
Health  Board  gave  funds  to  supplement  the  ap- 
propriations of  state  boards  of  health  for  insti- 
tute teaching.  A  small  contribution  was  also 
made  to  a  state  department  which  is  testing  the 
possibilities  of  correspondence  instruction  for 
local  health  officers  and  their  staffs. 

The  Pasteur  Institute  in  Paris  as  a  result  of  the 
war  was  seriously  threatened  not  only  with  cur- 
tailment of  its  activities,  but  with  a  lack  of  new 
workers  who  should  receive  training,  engage  in  re- 
search, and  thus  be  prepared  gradually  to  assume 
responsibility  for  the  future  of  this  world-famous 
center  and  its  several  branches.  To  supply  fel- 
lowships for  a  transition  period  and  to  help  defray 
the  costs  of  training  assistants  the  Foundation 
gave  330,000  in  1921  and  pledged  other  sums 
on  a  diminishing  scale  for  the  next  two  years. 


34       THE  ROCKEFELLER  FOUNDATION 

The  new  Ministry  of  Health  in  Czechoslovakia 
early  sought  the  co-operation  of  the  International 
Health  Board,  which  for  two  years  has  had  a 
resident  representative  in  Prague.  Fellowships 
for  health  training  in  the  United  States  were 
provided.  An  expert  in  public  health  laboratory 
organization  was  lent  to  the  Government. 
Next  a  plan  was  elaborated  for  creating  in  Prague 
an  institute  of  public  health  which  should  include 
central  laboratories  for  diagnostic  purposes,  for 
producing  vaccines  and  sera,  and  for  aiding  food 
inspection,  together  with  a  division  for  training 
health  officers.  A  complete  group  of  new  build- 
ings has  been  planned,  to  be  erected  on  an  easily 
accessible  and  ample  site  at  a  total  cost  for  land 
and  laboratories  of  about  3706,000,  of  which  the 
Foundation  has  promised  to  supply  3378,000,  or 
more  than  half. 

During  1921  the  International  Health  Board 
continued  to  contribute  toward  the  maintenance 
of  a  department  of  hygiene  in  the  medical  school 
of  Sao  Paulo,  Brazil.  While  a  professor  from  the 
United  States  was  in  charge,  young  Brazilian 
hygienists  who  were  trained  in  America  on 
Foundation  fellowships  assumed  increasing  re- 
sponsibility and  proved  themselves  capable  teach- 
ers and  promising  investigators. 

From  time  to  time  during  several  years  pro- 
posals have  been  made  to  establish  in  London  a 


PRESIDENT  S   REVIEW  35 

central  school  of  public  health.  In  June,  1921, 
a  Royal  Commission  recommended  that  such  an 
institution  be  created,  preferably  in  affiliation 
with  the  University  of  London.  The  possibilities 
of  carrying  out  this  recommendation  were  dis- 
cussed by  British  officials  with  representatives  of 
the  Foundation  and  the  International  Health 
Board  in  London  in  the  early  summer.  Later  a 
request  was  made  by  the  British  Ministry  of 
Health  for  the  co-operation  of  the  Foundation. 
This  was  considered  by  the  Board  and  negotia- 
tions were  authorized. 

The  Role  of  the  Nurse  in  Cure  and  Prevention 

The  modern  hospital  and  doctors  and  surgeons 
are  largely  dependent  upon  the  trained  woman 
nurse,  who  has  made  an  invaluable  contribution 
to  curative  medicine.  Public  health  administra- 
tors are  recognizing  the  visiting  or  health  nurse 
as  equally  indispensable  to  the  success  of  public 
and  personal  hygiene.  Already  maternity  and 
child  welfare  nurses,  school  nurses,  tuberculosis 
nurses,  and  several  other  specialized  types  have 
taken  their  places  in  private  health  systems  and 
in  government  departments.  One  state  has  an- 
nounced as  its  goal  the  appointment  of  a  health 
nurse  for  every  2,000  of  the  population;  another 
has  fixed  the  ratio  at  one  to  3,000. 

Questions  as  to  the  exact  function  of  the  bed- 


36       THE  ROCKEFELLER  FOUNDATION 

side  nurse,  the  kind  and  length  of  training  she 
should  receive,  have  been  under  discussion  for 
some  time.  The  advent  of  the  health  nurse 
raises  similar  problems.  How  far  should  her 
education  coincide  with  that  of  the  hospital 
nurse.'*  In  what  should  consist  her  special 
training?  How  much  time  should  the  entire 
course  occupy?  Should  there  be  different  grades 
of  both  bedside  and  health  nurses?  Are  there 
place  and  function  for  a  lay  worker  or  a  health- 
visitor?  In  1919  the  Foundation  invited  a 
group  of  persons  who  are  most  familiar  with 
nursing  problems  to  a  conference  which  nomi- 
nated a  survey  committee  under  whose  auspices  a 
competent  expert  has  been  making  a  study  of  the 
subject  in  all  its  phases.  A  report  is  promised  in 
the  summer  of  1922.  The  expenses  of  the  survey 
have  been  met  by  the  Foundation. 

During  1921  the  International  Health  Board 
contributed  toward  short  courses  for  New  York 
State  nurse  training.  Four  nurse  training  cen- 
ters in  France  were  aided  not  only  to  train 
visiteuses  d''hygiene  but  to  improve  in  certain 
hospitals  standards  of  ward  nursing  and  ad- 
ministration. The  Cavell-Depage  Memorial 
School  of  Nursing  in  Brussels  will  be  an  integral 
part  of  the  reorganized  hospital  and  medical 
school  to  which  the  Foundation  is  contributing  a 
large  sum.     The  International  Health  Board  is 


PRESIDENT  S    REVIEW  37 

co-operating  with  the  government  of  Brazil  in 
developing  a  public  health  nursing  service.  The 
Foundation  supports  a  nurse  training  school  in 
connection  with  the  Peking  Union  Medical  Col- 
lege. A  survey  of  nurse  training  in  Great  Britain 
and  on  the  Continent,  to  be  begun  early  in  1922, 
has  been  authorized.  Scholarships  were  granted 
to  four  Polish  nurses  for  study  and  training  in  the 
United  States. 

Medical  Service  at  Moderate  Cost 

A  modern  clinic  may  serve  the  interests  of  both 
preventive  and  curative  medicine.  Persons  may 
resort  to  it  to  make  sure  that  they  are  well  or  to 
have  their  diseases  recognized  and  treated. 
Diagnostic  and  treatment  facilities  are  now 
available  in  cities  and  large  towns  for  the  rich 
and  well-to-do  and  for  the  very  poor,  but 
self-respecting  people  of  small  means  are  too 
often  at  a  loss  for  good  medical  aid.  It  is  true 
that  the  leading  consultants  and  specialists  make 
concessions  in  individual  cases  but  this  generous 
attitude  of  the  profession  solves  only  a  minute 
part  of  the  problem.  The  tendency  to  establish 
medical  group  clinics  makes  it  easier  to  provide 
modern  facilities  at  lower  cost,  but  at  best  the  fees 
are  considerable,  and  many  people  hesitate  to  ask 
for  a  concession  in  charges.  Hence  the  demand 
for  a  pay  clinic  for  persons  with  small  incomes.. 


38        THE  ROCKEFELLER  FOUNDATION 

An  experiment  in  meeting  this  demand  was 
begun  by  the  Cornell  University  Medical  School 
in  New  York  City  in  November,  1921,  with  the 
co-operation  of  a  special  committee  of  the 
United  Hospital  Fund.  The  work  of  this  com- 
mittee, which  is  helping  to  improve  standards  of 
dispensary  management  and  service,  is  supported 
by  the  Rockefeller  Foundation.  The  initial 
deficit  of  the  Cornell  clinic  demonstration,  which 
is  expected  to  become  self-supporting,  was  under- 
written by  this  committee. 

The  essentials  of  the  plan  are:  (1)  medical, 
surgical,  and  specialist  service  by  well-trained 
young  doctors,  who  are  paid  for  their  work,  (2) 
supervision  by  the  college  faculty,  (3)  instruc- 
tion of  medical  students  in  the  clinic,  (4)  appoint- 
ments with  patients  made  by  telephone  or  post  to 
avoid  waste  in  waiting,  (S)  clinics,  in  addition  to 
day  sessions,  open  two  evenings  a  week  for  the 
convenience  of  patients  employed  during  the  day, 
(6)  a  charge  of  ?1.00  for  each  call,  laboratory 
examinations  and  X-ray  plates  at  cost,  a  complete 
diagnostic  examination  for  patients  referred  by 
physicians  for  an  inclusive  fee  of  310.00.  On  the 
day  the  clinic  opened  700  persons  presented 
themselves.  There  has  been  a  steadily  growing 
patronage  ever  since.  An  increasing  number  of 
doctors  have  brought  patients  for  diagnosis  and 
consultation.     It   is    too    early   to    assert    that 


president's  review  39 

clinics  of  this  kind  will  satisfactorily  solve  the 
problem,  but  experience  so  far  has  been  distinctly 
significant  and  encouraging. 

A  Medical  Center  Opened  in  Peking 

On  September  19,  1921,  in  the  capital  of  China 
a  unique  academic  procession  made  its  way 
through  oriental  corridors  and  courts  to  an  as- 
sembly hall  which  in  its  exterior  form  and  decora- 
tions reproduced  the  classic  features  of  Chinese 
architecture.  The  cortege  was  a  blending  of 
East  and  West.  Chinese  officials  and  other  lead- 
ing citizens,  some  of  them  in  national  dress, 
members  of  the  diplomatic  corps,  distinguished 
guests  in  the  variegated  brilliant  gowns  and 
hoods  of  European  and  American  universities, 
the  officers,  trustees,  and  faculty  of  the  Peking 
Union  Medical  College,  all  in  academic  garb, 
made  a  striking  and  symbolic  picture.  Brief 
words  of  greeting  and  appreciation  from  represen- 
tatives of  the  President  of  China,  the  Cabinet, 
the  medical  profession  and  educational  institu- 
tions, a  statement  by  the  Director  of  the  China 
Medical  Board,  an  address  on  the  aims  and  spirit 
of  the  College  by  the  Chairman  of  the  Board  of 
the  Rockefeller  Foundation,  and  the  institution 
in  its  new  setting  and  with  enlarged  resources  was 
rededicated  to  the  service  of  the  Chinese  people. 

These  simple  ceremonies  were  one  session  of  a 


40       THE  ROCKEFELLER  FOUNDATION 

program  which  extended  over  an  entire  week  and 
included  daily  cHnics,  scientific  papers  on  medical 
and  pubHc  health  themes,  popular  evening  ad- 
dresses, sight-seeing  excursions,  a  garden  party 
at  the  Summer  Palace,  a  reception  by  the  Presi- 
dent of  China,  dinners  and  receptions  at  the 
American  and  British  legations.  In  addition  to 
a  score  of  special  guests  of  the  Foundation  from 
England,  France,  Ireland,  Canada,  Japan,  China, 
the  Philippines,  Hong  Kong,  and  Java,  more 
than  three  hundred  medical  and  educational 
delegates,  Chinese  and  foreign,  were  in  attend- 
ance on  what  was  actually  an  international  con- 
gress of  curative  and  preventive  medicine.  The 
clinics  and  papers  were  rated  by  competent 
judges  as  highly  scientific  and  significant.  The 
contributions  of  the  members  of  the  Peking 
faculty  made  a  most  favorable  impression  upon 
the  visiting  scientists. 

The  buildings  of  the  College  were  admired 
both  for  their  architectural  beauty  and  for  their 
practical  serviceability  and  complete  equipment. 
All  the  essential  laboratories  and  lecture  rooms,  a 
hospital  of  225  teaching  beds,  and  an  outpatient 
department,  are  provided.  The  entire  plant 
comprises  for  purposes  of  instruction,  for  faculty 
and  student  quarters,  for  mechanical  services 
and  storage,  an  area  of  about  twenty-five  acres 
and  a  total  of  fifty-nine  buildings.     It  was  neces- 


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Fig.    9. — Academic    procession    at    dedication    of 
Peking  Union  Medical  College 


Fig.  10. — Part  of  academic  procession,  dedication  of 
Peking  Union  Medical  College,  September  19,  1921.  From 
right  to  left:  Dr.  W.  W.  Yen,  Minister  of  Foreign  Affairs; 
Mr.  Roger  S.  Greene,  Director  of  the  China  Medical 
Board;  Dr.  H.  S.  Houghton,  Director  of  the  Peking  Union 
Medical  College;  Mr.  John  D.  Rockefeller,  Jr.,  Chairman 
of  the  Board  of  Trustees  of  the  Rockefeller  Foundation 


PRESIDENT  S   REVIEW  43 

sary  not  only  to  build  a  medical  school  and 
hospital  but  to  add  to  them  the  housing,  water 
supply,  sewerage,  electric  Hght,  and  fuel  gas 
services  of  a  modern  community.  The  cost  of 
construction  was  enormously  increased  by  the 
war.  Prices  soared,  freight  rates  rose,  silver  so 
increased  in  value  that  at  one  time  a  gold  dollar 
would  purchase  slightly  less  than  one  silver  dol- 
lar instead  of  the  normal  two. 

On  June  30,  1921,  the  teaching  staif  of  this 
Peking  center  numbered  sixty-seven,  of  whom 
seventeen  were  instructors  in  the  pre-medical 
school.  About  one  fourth  of  the  total  teaching 
corps  were  Chinese,  almost  all  of  whom  were 
trained  in  the  United  States  or  Europe.  Besides 
the  educational  personnel  there  were  fifteen 
hospital  interns  and  residents,  twenty-eight 
nurses,  twenty-nine  members  of  the  business  and 
administrative  departments,  twenty-two  secre- 
taries, eleven  technicians,  librarians,  and  others. 
The  service  group  of  assistants,  attendants, 
messengers,  cooks,  waiters,  stokers,  janitors, 
totaled  601,  practically  all  Chinese.  The  stu- 
dent registration  for  1921-1922  showed  fifty-two 
in  the  pre-medical  school,  twenty  in  the  medical 
school,  and  eleven  in  the  nurses  training  school. 
For  the  previous  year  forty-nine  advanced  stu- 
dents were  registered  for  graduate  and  special 
courses.     This  number  is  likely  to  be  exceeded 


44       THE  ROCKEFELLER  FOUNDATION 

during  the  current  session.  The  total  number  of 
students  for  the  year  will  approximate  140.  The 
fact  that  only  a  small  number  of  preparatory 
schools  and  colleges  can  meet  the  entrance 
standard,  the  length  and  cost  of  the  medical 
course,  the  popular  ignorance  of  modern  medicine, 
are  obstacles  to  be  slowly  overcome.  In  all  the 
circumstances  the  present  numbers  are  distinctly 
encouraging. 

The  College  seeks  quality  rather  than  quan- 
tity. It  aims  not  to  turn  out  numerous  doctors 
— Chinese  institutions  must  assume  this  task — 
but  to  train  leaders  who  may  serve  as  teachers 
and  investigators  in  Chinese  medical  schools, 
hospitals,  and  health  organizations.  In  its  own 
work  it  proposes  to  develop  Chinese  teachers, 
who  already  constitute  25  per  cent  of  the  teach- 
ing staff,  and  to  give  them  increasing  rank  and 
responsibility  as  rapidly  as  they  are  prepared  to 
assume  them.  The  officially  announced  pur- 
poses of  the  Peking  Union  Medical  College  are: 
to  conduct  a  high-grade  medical  curriculum  for 
undergraduates,  to  provide  graduate  training  for 
laboratory  workers,  teachers,  and  clinical  spe- 
cialists, to  offer  short  courses  for  physicians,  to 
furnish  opportunities  for  research,  especially  in 
diseases  peculiar  to  the  Far  East,  and  incidentally 
to  extend  the  popular  knowledge  of  modern 
medicine  and  public  health  among  the  Chinese. 


PRESIDENT  S    REVIEW  45 

The  trustees  devoted  a  week  in  Peking  to  de- 
tailed consideration  of  the  problems  of  the  Col- 
lege and  adopted  a  policy  which  calls  for:  (1) 
gradual  growth  rather  than  rapid  expansion, 
within  (2)  budget  limits  fixed  for  three  years  at 
not  more  than  31,200,000  silver  (about  ?700,000 
gold),  per  annum,  (3)  the  gradual  transfer  of  the 
responsibility  for  pre-medical  education  to  other 
schools  and  colleges,  (4)  the  training  of  Chinese 
men  and  women  to  assume,  as  fast  as  they  show 
the  necessary  capacity,  increasing  responsibility 
for  teaching,  investigation,  and  administration, 
(S)  the  encouraging  of  Chinese  co-operation  in 
the  increasing  of  clinical  facilities  by  establishing 
under  Chinese  auspices  special  dispensaries  and 
hospitals,  (6)  a  steady  effort  to  enlist  the  interest 
and  secure  the  aid  of  public-spirited  Chinese  in 
interpreting  the  purposes  of  the  college  to  the 
Chinese  people. 

In  addition  to  their  regular  duties  members  of 
the  faculty  of  the  College  during  the  year  partic- 
ipated in  famine  relief,  worked  out  a  food  ration 
as  a  basis  for  distribution  of  food  to  famine  suf- 
ferers, provided  medical  consultation  service  for 
a  Chinese  orphanage,  visited  many  educational 
institutions  to  give  expert  counsel  about  ap- 
paratus and  X-ray  equipment,  organized  typhus- 
prevention  squads  to  protect  the  refugee  camps 
and  the  city  of  Peking,  rendered  a  large  amount 


46       THE  ROCKEFELLER  FOUNDATION 

of  private  medical  and  surgical  service  the  fees 
for  which  went  into  the  treasury  of  the  College, 
assisted  in  archeological  research,  and  in  many 
other  ways  entered  into  the  life  of  the  capital  and 
the  country. 

The  China  Medical  Board,  under  whose  aus- 
pices work  in  China  is  administered,  in  addition 
to  completing  and  maintaining  the  College  in 
Peking,  authorized  a  survey  of  pre-medical  educa- 
tion, contributed  to  the  expenses  of  a  commission 
sent  by  a  group  of  missionary  societies  to  study 
and  report  upon  education  under  missionary 
auspices  in  China,  made  appropriations  to  a 
language  school  and  a  school  for  foreign  children 
in  Peking,  contributed  to  a  dental  clinic  in  return 
for  service  to  the  college  hospital,  gave  mainte- 
nance funds  to  two  mission  medical  schools,  made 
a  small  gift  to  a  Chinese  medical  school,  con- 
tinued appropriations  which  had  been  pledged  to 
five  pre-medical  schools,  seventeen  hospitals, 
and  to  a  committee  for  translating  medical  books 
into  Chinese,  and  awarded  fellowships  for  study 
in  the  United  States. 

Medical  Education  in  Many  Lands 

Columbia  University  in  behalf  of  its  medical 
school  has  made  an  arrangement  with  the 
Presbyterian  Hospital  by  which  on  a  new  up- 
town site  in  New  York  a  combined  medical  school 


PRESIDENT*S   REVIEW  47 

and  hospital  group  will  be  built.  This  will  be 
one  of  the  most  complete  and  best  equipped 
medical  centers  in  the  world.  Toward  the  sum 
needed  for  building  operations  and  increased 
maintenance  the  Foundation  agreed  to  contrib- 
ute 21,000,000. 

During  1921  contracts  were  signed  with  the 
University  of  Brussels,  the  Hospital  Board  of 
Brussels,  and  the  municipality  itself,  by  which 
the  Rockefeller  Foundation  agreed  to  give 
23,500,000  toward  the  cost  of  concentrating  upon 
one  site  and  completely  rebuilding  the  medical 
laboratories  and  the  antiquated  hospital  of  St. 
Pierre.  The  Cavell-Depage  Memorial  Nurses' 
Home  and  Training  School  will  be  an  integral 
part  of  the  project.  The  new  buildings  designed 
by  a  leading  Belgian  architect  will  constitute  the 
most  modern  and  convenient  medical  training 
plant  in  Europe. 

In  further  distribution  of  the  ?S,000,000  set 
aside  in  1920  to  aid  medical  education  in  Canada 
the  following  sums  were  voted  during  1921:  to 
Dalhousie  University  to  meet  an  emergency 
which  arose  in  connection  with  a  maternity  hospi- 
tal, 250,000;  to  the  University  of  Montreal  medi- 
cal school  for  strengthening  pre-medical  science 
teaching,  225,000;  to  the  University  of  Alberta 
for  clinical  instruction,  225,000.  The  pledge  of 
21,000,000  to  McGill  University  was  paid. 


48  THE  ROCiECEFELLER  FOUNDATION 

During  the  year  the  Foundation  suppUed  the 
funds  by  which  thirty-eight  medical  centers  in 
Central,  Western,  and  Southern  Europe  received 
current  numbers  and  back  files  of  the  principal 
journals  of  the  medical  sciences  published  in 
English.  Without  this  aid  it  would  have  been 
impossible  in  view  of  present  rates  of  exchange 
for  these  institutions  to  secure  any  considerable 
number  of  these  important  publications.  In  ad- 
dition to  the  3100,000  voted  in  1920  for  apparatus 
and  supplies  sorely  needed  by  five  universities  in 
Central  Europe,  an  additional  sum  of  350,000 
was  last  year  appropriated  for  the  same  purpose. 

With  the  aim  of  gathering  accurate  data  about 
medical  education  in  many  countries,  representa- 
tives of  the  Foundation  made  surveys  of  medi- 
cal schools  in  Japan,  China,  Hong  Kong,  the 
Philippines,  Siam,  Indo-China,  Straits  Settle- 
ments, Java,  Egypt,  Syria,  and  Constantinople. 
Less  thorough  studies  were  made  of  several 
schools  in  India. 

Envoys  of  Science  and  Education 

Bacon  in  the  New  Atlantis  describes  an  ideal 
commonwealth  based  upon  scientific  research 
and  the  application  of  its  results  to  the  life 
of  the  people.  One  of  the  officials  in  explain- 
ing the  organization  of  the  staif  to  foreign  visitors, 
says:  "For  the  several  employments  and  offices 


PRESIDENT  S    REVIEW  49 

of  our  fellows,  we  have  twelve  that  sail  into 
foreign  countries  .  .  .  who  bring  us  the 
books  and  abstracts,  and  patterns  of  experi- 
ments of  all  other  parts.  These  we  call  mer- 
chants of  light."  Bacon  saw  that  science  suffers 
not  only  from  provincialism  but  from  national- 
ism. The  search  for  truth  and  its  application  to 
human  need  is  a  vast,  world-wide  co-operative 
task  which  demands  constant  interchange  of 
ideas  and  more  intelligent  team-work  among 
workers.  Every  country  should  seek  entangling 
alliances  in  a  league  for  scientific  progress. 

During  1921  the  Foundation  made  a  contribu- 
tion to  world  commerce  in  ideas.  Its  own  rep- 
resentatives visited  Europe,  the  Near  East,  the 
Far  East,  India,  and  South  and  Central  America. 
Resident  directors  of  health  demonstrations  were 
maintained  in  twenty-three  foreign  countries. 
From  all  these  men  and  women  came  reports, 
memoranda,  and  printed  matter  which  enriched 
the  files  of  the  central  office  and  supplied  ideas 
and  suggestions,  many  of  which  will  be  at  the 
disposal  of  individuals  and  institutions  in  this 
and  other  countries. 

At  the  invitation  of  the  Foundation  individuals 
and  groups  visited  the  United  States  and  Great 
Britain  as  envoys  of  science,  "merchants  of 
light."  Two  heads  of  departments  in  University 
College  Hospital  Medical  School,  London,  made 


50       THE  ROCKEFELLER  FOUNDATION 

a  tour  of  the  leading  medical  schools  of  the 
United  States  and  Canada.  The  executive 
secretary  of  the  Medical  Research  Council  and 
the  ^chairman  of  the  Medical  Division  of  the 
University  Grants  Committee  of  Great  Britain 
followed  much  the  same  itinerary.  The  presi- 
dent of  the  hospital  board  of  Brussels  and  the 
architect  of  the  new  medical  buildings  visited 
England  and  the  United  States  to  study  the 
architecture  and  administration  of  hospitals  and 
laboratories.  Clinical  professors  of  the  Brussels 
University  Medical  School  spent  some  time  in 
London  to  observe  the  operation  of  full-time 
units  in  medicine  and  surgery  and  the  use  of  out- 
patient departments  in  teaching.  A  Serbian 
Commission  visited  the  United  States  and 
England  to  familiarize  its  members  with  methods 
of  medical  education  and  of  public  health  ad- 
ministration. A  noted  Brazilian  physician,  the 
Director  of  the  National  Department  of  Health 
and  of  the  Oswaldo  Cruz  Institute,  came  with  one 
of  his  colleagues  to  visit  medical  schools  and  to 
study  public  health  laboratories  and  practical 
field  methods. 

Student  Fellows  from  Eighteen  Countries 

One  hundred  and  fifty-seven  individuals  dur- 
ing 1921  held  fellowships,  funds  for  which  were 
4irectly  or  indirectly  supplied  by  the  Rockefeller 


PRESIDENT  S    REVIEW  5I 

Foundation.  These  fellowships  fell  into  five 
groups:  (1)  fifty-four  fellowships  in  public 
health  under  the  International  Health  Board,  (2) 
fifty-two  fellowships  administered  by  the  China 
Medical  Board,  (3)  sixteen  fellowships  in  medical 
education,  (4)  thirty-four  research  fellowships  in 
physics  and  chemistry  supervised  by  a  special 
committee  of  the  National  Research  Council, 
and  (5)  one  member  of  the  International  Health 
Board  staff  who,  on  what  is  known  as  "study 
leave,"  was  engaged  in  special  study.  The  dis- 
tribution of  these  fellows  by  countries  was: 
seventy-one  Americans,  one  Belgian,  seven  Bra- 
zilians, eleven  Canadians,  one  Singhalese,  seven- 
teen Chinese,  one  Colombian,  two  Costa  Ricans, 
nineteen  Czechs,  seven  British,  four  French,  one 
Guatemalan,  one  Mexican,  two  Nicaraguans, 
seven  Poles,  two  Salvadoreans,  two  Syrians,  one 
Norwegian. 

The  increase  in  the  number  of  Foundation 
fellowships  during  the  last  few  years  is  significant. 
In  1917  there  were  sixty-one;  by  1919  the  list  in- 
cluded eighty-four;  in  1920  there  were  120;  the 
maximum  for  1921,  as  has  been  already  indicated, 
was  157.  This  rapid  multiplication  of  fellowships 
reflects  the  conviction  that  the  training  of  men 
and  women  for  leadership  and  for  technical  ef- 
ficiency is  fundamental  to  progress  in  preventive 
medicine    and    in    medical    education..     Fellow- 


52       THE  ROCKEFELLER  FOUNDATION 

ships  are  granted  only  to  persons  of  exceptional 
promise  who  declare  their  intention  of  entering 
institutional  or  governmental  service.  Explicit 
official  assurances  that  posts  will  be  available 
when  the  training  has  been  completed  are  also 
required.  The  plan  is  beginning  to  show  en- 
couraging results.  Already  a  number  of  former 
fellows  are  occupying  positions  of  responsibility 
in  their  own  countries. 

The  fellowships,  which  are  administered  direct- 
ly by  the  Foundation  and  its  agencies,  are  super- 
vised by  a  special  officer  who  gives  most  of  his 
time  to  corresponding  with  candidates,  conferring 
with  newly  arrived  fellows,  advising  them  about 
institutions  and  professors,  helping  them  to  ar- 
range their  plans  of  study,  visiting  them  from 
time  to  time  in  the  cities  where  they  are  at  work, 
conferring  with  the  men  under  whom  they  are 
studying,  securing  periodic  reports  of  progress, 
dealing  with  emergencies,  arranging  for  special 
excursions,  and  in  other  ways  seeking  to  insure 
the  most  fruitful  use  of  the  opportunities  which 
the  fellowships  are  designed  to  provide. 

Yellow  Fever  in  Retreat 

The  salient  facts  about  yellow  fever  may  be 
summarized  as  follows:  probably  prevalent  in 
Aztec  times  in  Mexico  and  Central  America;  for 
last  two  centuries  a  dreaded  scourge  in  Mexico, 


t>kESit)ENT  S   REVIEW  53 

the  West  Indies,  Central  and  South  America, 
frequently  invading  North  American  ports  and 
causing  thousands  of  deaths  in  the  lower  Missis- 
sippi valley;  fact  of  transmission  by  bite  of  female 
Stegomyia  mosquito  established  by  American 
Army  Medical  Commission  under  Reed  in  Cuba, 
1900-1901;  Havana  and  Cuba  freed  from  fever 
by  Gorgas,  who  organized  anti-mosquito  meas- 
ures, 1901-1902;  example  followed  in  Rio  de 
Janeiro  and  Vera  Cruz,  1903-1909;  Panama- 
Canal  Zone  successfully  protected  by  same 
methods,  1904-1906;  fear  that  canal  traffic  might 
carry  disease  to  Far  East  and  the  confidence  of 
Gorgas  that  fever  could  be  eliminated  led  to  ap- 
pointment in  1916  by  International  Health 
Board  of  special  commission  to  survey  seed-beds 
of  infection;  Gorgas,  head  of  commission,  recom- 
mended a  campaign  of  extermination;  during 
delay  caused  by  war,  Noguchi  of  Rockefeller 
Institute  for  Medical  Research  visited  Ecuador, 
Peru,  and  Yucatan,  isolated  germ  believed  to  be 
inciting  cause  of  yellow  fever,  and  prepared 
vaccine  and  serum,  1918-1920;  yellow  fever  com- 
missions organized  in  Central  American  countries, 
Colombia,  Venezuela,  Ecuador,  and  Peru;  inten- 
sive campaign,  1918-1919,  under  Connor  elimi- 
nated disease  from  Guayaquil,  the  chief  endemic 
center;  1920,  commission  sent  to  West  Coast  of 
Africa  to  investigate  suspected  areas;  with  oc- 


54  THE  ROCitEFELLER  FOUNDATION 

casional  outbreaks,  most  of  them  traceable  to 
places  in  Southern  Mexico,  the  fever  gradually 
gave  ground;  late  in  1920  Mexican  government 
organized  commission  and  invited  co-operation  of 
International  Health  Board. 

Up  to  the  beginning  of  1921  experience  with 
Noguchi's  vaccine  and  serum  indicated  that  the 
former  when  properly  administered  aifords  a 
marked  protection  against  attacks  of  yellow 
.fever,  and  that  the  latter  if  it  is  used  on  or  before 
the  third  day  of  the  onset  of  the  disease  reduces 
the  mortality  in  a  striking  way.  Data  reported 
during  last  year  confirm  these  conclusions.  In 
Peru,  of  a  group  of  fifty  non-immune  soldiers 
who  were  being  sent  into  an  infected  district, 
twenty-five  were  vaccinated  and  twenty-five 
were  left  unvaccinated.  Twenty  of  the  latter 
group  contracted  yellow  fever,  while  no  case  of 
the  disease  occurred  among  members  of  the 
former.  Of  twelve  yellow  fever  patients  in 
Belize,  Honduras,  who  were  treated  with  serum 
on  or  before  the  third  day  of  the  attack,  eleven 
recovered.  Until  yellow  fever  is  eradicated  at 
its  sources,  the  vaccine  and  serum  promise  to  be 
most  valuable  means  of  prevention  and  cure. 

With  the  entrance  of  the  Mexican  government 
early  in  1921  into  the  yellow  fever  campaign  the 
prospects  of  successful  advance  brightened.  The 
chief   remaining   sources   of  infection   were   at- 


president's  review  55 

tacked.  During  1921  Ecuador,  Honduras,  Nic- 
aragua, and  Costa  Rica  were  not  invaded  by 
the  disease.  Guatemala  reported  no  case  after 
February  2;  Salvador's  last  case  was  recorded 
February  IS;  by  July  16  Peru  was  free,  as  was 
British  Honduras  in  November.  From  North- 
ern Brazil  cases  were  reported  but  the  situation 
was  being  dealt  with  by  the  government.  It 
was  gratifying  to  the  Foundation  to  be  able  to 
advance  money  for  continuing  the  campaign  in 
Peru  at  a  time  when  government  funds  were  not 
quickly  available.  The  advantages  of  having 
resources  which  could  be  immediately  mobilized 
in  an  emergency  were  strikingly  demonstrated. 
It  was  another  example  of  the  efficiency  of  a  uni- 
fied plan  of  co-operation.  The  outlook  is  en- 
couraging; it  is  too  early  to  proclaim  a  complete 
victory,  but  the  purpose  to  push  the  fight  against 
yellow  fever  remains  steadfast. 

Howard  B.  Cross  on  the  Honor  Roll  of  Science 

Dr.  Jesse  Lazear,  one  of  the  Army  commis- 
sion in  Cuba,  gave  his  life  for  science  and  his 
fellow  men  as  the  direct  result  of  his  studies 
of  yellow  fever.  Such  courage  knows  no  stimu- 
lus of  dramatic  excitement,  of  martial  music, 
of  stirring  battle  charge.  The  list  headed  by 
Lazear,  of  brave  men  and  women  who  have 
died   in   investigating   yellow   fever   or   in   car- 


5^       THE  ROCKEFELLER  FOUNDATION 

Ing  for  its  victims,  is  a  long  and  noble  roll  of 
honor. 

To  this  roll  has  been  added  during  recent 
months  the  name  of  Howard  B.  Cross,  of  the 
staff  of  the  Rockefeller  Institute  for  Medical 
Research,  who,  after  special  work  with  Noguchi, 
went  to  Mexico  under  the  auspices  of  the  Inter- 
national Health  Board  to  assist  in  the  diagnosis 
of  doubtful  and  complicated  cases  of  genuine  or 
suspected  yellow  fever.  He  sailed  from  New 
York  November  23,  landed  at  Vera  Cruz,  fell  ill 
in  the  village  of  Tuxtepec  December  18,  and  re- 
turned to  Vera  Cruz,  where  he  died  of  yellow 
fever  December  26,  1921. 

The  Mexican  authorities  and  the  Mexican 
medical  profession  did  all  in  their  power  to  show 
their  sympathy  and  admiration.  The  utmost 
courtesy  and  consideration  were  manifested.  By 
formal  resolutions,  guards  of  honor,  and  other 
evidences  of  respect  and  appreciation,  their  good 
will  and  gratitude  were  warmly  expressed.  The 
public  health  laboratory  of  Vera  Cruz  has  been 
named  the  Howard  B.  Cross  Laboratory. 

Dr.  Cross,  born  in  1888,  was  graduated  from 
the  University  of  Oklahoma,  served  as  instructor 
in  zoology  for  two  years,  was  a  graduate  student 
at  the  University  of  Chicago  and  at  Johns  Hop- 
kins University.  In  1917  he  married  Miss  Ollie 
DeBoard.     In  June,  1921,  he  received  the  degree 


president's  review  57 

of  Doctor  of  Philosophy  from  the  latter  institu- 
tion, where  he  had  specialized  in  bacteriology. 
In  1918  Dr.  Cross  had  enlisted  in  the  United 
States  Army  Medical  Corps  and  was  assigned  to 
the  Johns  Hopkins  Medical  School  for  special 
investigative  work. 

This  young  American,  well-trained,  devoted  to 
the  search  for  truth,  loyal  to  a  great  cause,  died 
gallantly  in  combating  a  dread  plague.  By  his 
death  science  has  lost  an  able  and  conscientious 
worker,  and  the  world  a  brave  and  generous 
spirit. 

Continued  Demonstrations  in  the  Control  of 
Malaria 

The  primary  object  of  the  International 
Health  Board  and  the  allied  Federal  and  state 
health  organizations  in  undertaking  malaria 
work  in  1916  was  to  prove  to  small  towns,  vil- 
lages, and  rural  communities  that  malaria  can  be 
practically  eradicated  at  per  capita  costs  which 
make  elimination  cheaper  than  harboring  the 
disease.  The  campaigns  were  based  upon  two 
scientific  facts :  (a)  malaria  can  be  communicated 
only  by  the  bite  of  the  Anopheles  mosquito,  and 
(b)  almost  all  sufferers  from  malaria  can  be 
cured  by  the  administration  of  quinine  in  proper 
doses  over  a  sufficient  period  of  time.  The  pre- 
vention of  mosquito  breeding  by  drainage,  by 


58 


THE  ROCKEFELLER  FOUNDATION 


surface  oiling  of  standing  water,  by  the  use  of  fish 
which  eat  the  mosquito  larvae;  the  protection  of 
people  by  screening  beds  and  houses,  by  removal 
of  houses  from  the  vicinity  of  breeding  places, 
by  the  killing  of  adult  mosquitoes;  the  use  of 
quinine  when  mosquito  control  is  too  difficult, 
have  been  tried  in  various  combinations,  most 


DEATHS    FROM 
MALARIA 

IN  L0U/3IAm  m  1918-19/9-/920 


AM  JHt  /i,-JOmEL£S  MOSQUITO 

I  duse  mesE  deaths 

/  HILLED  MANy  MORE  IN  PREVIOUS 

YEARS  AND  EXPECT  TO  K/LL 

MORE  in  yEARS  TO  COME 
I  ALSO  CAUSE MANy  TWt/SAND  CASES 

"  SlCWfSS  m  COST  LOUISIANA 
UmT  «^.000,000^  A  YEAR 

WHAT  ARE  YOU  GOING  TO  DO  ABOUT  IT? 


LOUISIANA 
STATE  BOARD     OF   HEALTH 


Fig.  11. — Map  used  in  anti-malaria  campaign  in  Louisi- 
ana. Each  dot  represents  a  death  from  malaria.  The 
public  health  importance  of  malaria,  however,  is  more 
accurately  measured  by  the  sickness  rate  and  the  loss  of 
efficiency  than  by  the  loss  of  life.  It  has  been  estimated 
that  for  each  death  2,000  to  4,000  days  of  sickness  must 
be  included  in  the  total  burden  of  loss  and  suffering  caused 
by  the  malaria  niosquito 


PRESIDENT  S    REVIEW  59 

of  them  with  a  success  that  has  been  strikingly 
convincing. 

For  the  past  two  years  demonstrations  have 
been  carried  on  in  conjunction  with  local  authori- 
ties, state  boards  of  health,  and  the  United  States 
Public  Health  Service.  During  1921  in  nine 
southern  states  new  demonstrations  were  under- 
taken in  twenty-six  localities,  while  supervision 
of  work  previously  inaugurated  was  continued  in 
thirty-five  places  in  ten  states.  Reports  indicate 
that  substantial  reductions  in  the  prevalence  of 
the  disease  were  effected  at  an  average  per  capita 
cost  of  31 .01 .  Reductions  secured  by  demonstra- 
tions made  in  1920  were  maintained  at  an  aver- 
age cost  of  $.2S  per  capita. 

Investigations  as  to  the  adaptation  of  anti- 
malaria  measures  to  tropical  conditions  were 
started  in  Porto  Rico  and  Nicaragua.  Prelimi- 
nary studies  were  also  made  in  Argentina  and 
elsewhere  to  discover  variations  in  conditions  to 
be  dealt  with.  Experiments  in  treatment  by 
quinine  were  concluded  in  Sunflower  county, 
Mississippi,  where  by  experimental  methods  a 
standard  dose  of  this  drug  calculated  to  protect 
individuals  had  previously  been  worked  out  and 
has  now  been  made  available  to  the  public 
through  commercial  channels  at  a  cost  of  31.95. 

In  addition  to  continued  investigations  in  vari- 
ous methods  of  rnosquito  control,  including  the 


60       THE  ROCKEFELLER  FOUNDATION 

use  of  fish,  surveys  were  undertaken  in  two  re- 
gions in  the  South  to  determine  the  prevalence  of 
malaria  and  the  part  which  it  plays  in  impairing 
the  health  and  efficiency  of  a  given  population. 
One  report  for  an  area  in  Southeast  Missouri  was 
completed  and  confirms  the  belief  held  by  many 
that  this  disease,  although  less  severe  than  in 
former  years,  is  still  a  crippling  malady  which  not 
only  impairs  vitality,  increases  suffering,  de- 
presses the  community  spirit,  but  adds  directly 
and  substantially  to  the  death  rate. 

The  Hookworm  Story  of  One  County 

In  the  spring  of  1910  a  hookworm  survey  was 
made  of  the  school  children  of  a  Virginia  county. 
This  study  showed  that  82.6  per  cent  of  the  pupils 
were  infected,  and  there  was  reason  to  believe 
that  a  high  percentage  prevailed  in  the  population 
as  a  whole.  There  were  plenty  of  external  evi- 
dences of  the  malady.  Individuals  were  pale, 
listless,  and  weak.  Many  were  bed-ridden. 
The  rich  soil  ill-cultivated  produced  a  bare  living. 
School  attendance  was  small  and  the  children  who 
were  enrolled  made  little  progress.  Local  insti- 
tutions languished;  social  life  was  primitive,  com- 
munity spirit  lacking,  moral  standards  low.  The 
people  were  carrying  a  crippling  load.  Greedy 
parasites  were  robbing  their  blood.  A  polluted 
soil  was  maintaining  the  vicious  circle  of  infection. 


PRESIDENT'S   REVIEW  6l 

The  Rockefeller  Sanitary  Commission,  later 
merged  in  the  International  Health  Board,  began 
at  once  in  co-operation  with  the  Virginia  State 
Board  of  Health  an  anti-hookworm  campaign 
under  the  leadership  of  a  devoted  and  able  local 
physician  whom  the  people  knew  and  trusted. 
Clinics  were  organized,  the  cause,  cure,  and  pre- 
vention of  hookworm  disease  were  explained  to 
the  public,  curative  drugs  were  administered, 
sanitary  conveniences  were  introduced.  Fifteen 
months  later  a  second  school  survey  showed  that 
the  infection  had  been  reduced  to  35.2  per  cent. 
The  changes  in  the  life  of  the  community  were 
unmistakable.  The  glow  of  health  had  come  to 
once  pallid  faces,  chronic  invalids  had  returned 
to  active  work,  farms  gave  larger  returns,  the 
school  enrolment  had  increased,  pupils  were 
alert,  new  energy  and  spirit  manifested  them- 
selves in  neighborly  contacts  and  co-operation. 
But  the  work  was  not  abandoned.  Vigilance 
was  continued  and  to  good  purpose,  for  a  third 
survey  made  in  1921  showed  the  almost  negli- 
gible infection  of  2.2  per  cent.  In  a  little  more 
than  a  decade  a  radical  transformation  had 
occurred. 

Resurveys  of  many  other  counties  scattered 
through  the  Southern  States  were  made  during 
1921.  The  results  were  gratifying  and  encourag- 
ing.    They  showed  what  can  be  accomplished  by 


6^  TfiE  llOCKEFfeLLER  FOUNDATION 

persistent  attacks  upon  one  widely  prevalent 
disease.  They  will  spur  the  health  authorities 
to  renewed  effort  on  a  broader  scale.  Aid  in  the 
control  of  hookworm  disease  was  given  by  the 
International  Health  Board  to  governments  in 
eighteen  different  countries  in  South  and  Central 
America,  the  West  Indies,  India,  Ceylon,  Borneo, 
Siam,  and  Australia.  In  almost  every  case  the 
authorities  assumed  during  the  year  a  larger 
share  of  the  cost.  Investigations  were  also 
continued  into  the  nature  and  spread  of  hook- 
worm disease. 

Hookworm  Broadens  into  Health  Service 

The  process  of  widening  hookworm  work  into 
general  county  health  services  made  rapid  prog- 
ress during  1921.  The  International  Health 
Board  in  ending  its  specific  campaign  participated 
in  the  broader  programs  which  were  carried  out 
in  eleven  southern  states.  Before  the  end  of  the 
year  arrangements  had  been  made  to  aid  similar 
undertakings  in  seven  other  states.  Last  year 
192  counties  in  the  United  States  were  conduct- 
ing health  services  under  full-time  health  officers. 
To  the  health  budgets  of  seventy-seven  of  these 
counties  the  Board  contributed  on  the  average 
one  fourth  of  the  cost.  The  development  of 
county  health  work  in  Brazil  is  a  gratifying  out- 
growth of  the  hookworm  campaign  in  which  the 


president's  review  63 

International  Health  Board  had  been  participat- 
ing. 

County  health  measures  obviously  vary  with 
the  local  conditions.  Attacks  must  be  made 
upon  diseases  in  the  order  of  their  importance. 
Costs  must  be  kept  within  the  limits  of  the  funds 
available.  In  the  circumstances  the  plans  are 
necessarily  fairly  simple  and  inexpensive.  The 
average  campaign  includes:  vaccination  against 
typhoid  and  smallpox;  diphtheria  prevention- 
the  building  of  sanitary  fly-proof  latrines;  medi- 
cal inspection  of  school  children,  with  dental  and 
tonsil  clinics;  infant  and  maternal  welfare  work; 
control  of  communicable  diseases  in  general,  in- 
cluding special  attention  to  tuberculosis,  and 
popular  education  in  public  and  personal  hygiene. 

The  following  is  an  estimate  of  the  annual  cost 
of  a  full-time  health  administration  in  an  average 
county:  salaries — county  health  officer  33,000, 
sanitary  inspector  31,500,  nurse  31,500,  clerical 
assistant  3900;  traveling  expenses  for  these  per- 
sons 32,400;  contingent  fund  3700;  total  310,000. 
While  contributions  from  outside  sources  seem 
to  be  necessary  at  the  outset  it  is  believed  that 
fairly  prosperous  counties  should  be  able  to  meet 
*by  taxation  the  entire  cost  of  this  simpler  type 
of  health  service.  An  extension  of  the  program 
might  call  for  continued  state  and  Federal  aid  to 
supplement  local  funds. 


64       THE  ROCKEFELLER  FOUNDATION 

Tuberculosis  Campaign  in  French  Hands 

The  special  Commission  which  in  1917  was 
sent  to  France  under  the  auspices  of  the  Interna- 
tional Health  Board  to  aid  in  the  creation  of  a 
nation-wide  anti-tuberculosis  organization  was 
formally  disbanded  June  30,  1921.  Certain 
special  representatives  of  the  Board  remained  in 
France  to  complete  arrangements  for  the  final 
transfer  to  French  agencies,  governmental  and 
private,  of  the  functions  which  the  Commission 
had  been  performing.  These  activities  were  of 
four  kinds:  (1)  medical,  including  demonstration 
dispensaries  and  graduate  courses  for  physicians, 
(2)  training  of  public  health  visitors,  (3)  educa- 
tion of  the  public,  (4)  organization  of  depart- 
mental and  local  committees. 

Systems  of  tuberculosis  clinics  established  by 
the  Commission  in  the  nineteenth  arrondisse- 
ment  of  Paris  and  in  the  department  of  Eure-et- 
Loir  have  been  transferred,  together  with  certain 
sums  of  money,  to  the  municipal  and  depart- 
mental authorities.  The  number  of  dispensaries 
established  throughout  France  since  July,  1917, 
and  modeled  upon  these  demonstration  centers, 
has  reached  a  total  of  373,  a  substantial  propor- 
tion of  the  total  number  estimated  as  necessary 
to  give  the  nation  an  adequate  system  upon 
which   to  base  an  inclusive   program  of   early 


president's  review  65 

diagnosis,  health  visitors,  preventoria,  sanatoria, 
special  relief,  and  individual  and  public  educa- 
tion. 

From  training  schools  aided  by  Foundation 
funds,  249  health  visitors  have  been  graduated. 
Some  of  these  women  are  serving  as  depart- 
mental supervisors;  others  are  working  in  local 
dispensaries.  The  length  of  the  training  course 
has  been  extended  from  six  to  ten  months. 
Some  schools  are  now  requiring  two  years. 
Scholarships  both  for  physicians  and  nurses  in 
training  have  been  provided  by  the  Board  in 
large  numbers.  Salaries  for  supervising  and 
other  visitors  have  also  been  paid  from  the  same 
source.  Responsibility  for  these  forms  of  aid  is 
being  transferred  steadily  to  the  French. 

Active  educational  propaganda  by  means  of 
traveling  exhibits,  school  exercises,  public  meet- 
ings, groups  of  lecturers,  films  and  stereopticon 
slides,  posters,  pamphlets,  newspaper  articles, 
et  cetera,  has  been  carried  on  in  fifty-four  of  the 
ninety-three  departments  of  France.  Motor  cars, 
and  more  recently  a  special  railway  carriage,  have 
been  utilized.  This  function  is  being  gradually 
handed  over  to  the  Comite  National,  a  French 
society  for  combating  tuberculosis.  It  is  pro- 
posed to  create  under  the  auspices  of  the  Comite 
a  bureau  by  which  literature  will  be  issued  for 
distribution    through    departmental    and    local 


66       THE  ROCKEFELLER  FOUNDATION 

committees.  For  a  time  the  Board  will  continue 
to  support  two  traveling  educational  units. 

As  a  result  of  initiative  of  the  Foundation's  Com- 
mission eighty-eight  departmental  committees 
and  over  350  local  committees  have  been  formed. 
It  is  these  groups  which  help  to  organize  and 
support  dispensaries  and  to  promote  other  fea- 
tures of  the  plan.  While  the  Board  will  not  ex- 
tend this  organization  work  to  other  depart- 
ments, it  will  in  certain  places  give  counsel  and 
aid,  seeking  to  improve  organizations  and  to 
secure  appropriations  from  departmental  and  city 
treasuries.  This  task  of  organization  is  being  as- 
sumed more  and  more  by  the  Comite  National, 
to  which,  next  to  the  Ministry  of  Hygiene,  the 
Board  looks  for  the  continuation  and  extension 
of  the  anti-tuberculosis  movement  in  France. 

This  project  represents  the  only  effort  of  the 
International  Health  Board  in  the  field  of 
tuberculosis.  It  was  undertaken  as  a  form  of 
war-time,  emergency  aid.  There  is  no  intention 
of  doing  similar  work  in  other  countries.  The 
Board  had  no  thought  of  providing  a  complete 
system  for  combating  the  white  plague.  It  did 
not  assume  responsibility  for  hospitals,  sanatoria, 
or  direct  relief.  The  American  Red  Cross  during 
the  war  made  generous  appropriations  for  these 
purposes.  The  aim  of  the  International  Health 
Board  was  to  demonstrate  a  system  of  organiza- 


PRESIDENT'S    REVIEW  67 

tion,  of  special  training,  of  popular  education,  of  ex- 
tension methods.  It  hoped  to  stimulate  govern- 
ment and  voluntary  agencies  to  adopt  this  system 
on  a  national  scale  and  to  support  it  as  adequate- 
ly as  circumstances  would  permit.  Everything 
considered,  the  response  of  the  French  people 
has  been  remarkably  gratifying.  Up  to  the  end 
of  1921  the  Board  had  spent  upon  this  French 
campaign  about  two  million  dollars. 

Consultation  Service  and  Field  Studies 

During  the  year  1921  officers  and  special  rep- 
resentatives of  the  Rockefeller  Foundation  and 
its  agencies  gave  counsel  to  twelve  state  and 
national  governments  about  health  laboratory 
administration,  made  recommendations  to  medi- 
cal school  authorities  in  the  Far  East,  conferred 
with  officials  of  the  British  government  concern- 
ing the  problem  of  training  health  officers,  lent  a 
public  health  administrator,  a  sanitary  engineer, 
and  an  industrial  hygienist  to  the  Australian 
Ministry  of  Health,  contributed  toward  the  salary 
and  suppHes  of  a  pathologist  in  the  Sao  Paulo 
Medical  School,  Brazil,  and  in  other  ways  made 
information  and  suggestions  available  for  public 
authorities,  educational  institutions,  and  volun- 
tary health  agencies. 

In  addition  to  the  scientific  investigations  of 
hookworm   disease,   malaria,   and   yellow   fever 


68        THE  ROCKEFELLER  FOUNDATION 

which  have  already  been  mentioned,  the  Founda- 
tion supported  studies  of  pre-medical  education 
in  China,  of  nurse  training,  of  dispensary  de- 
velopment, of  hospital  administration,  and  the 
training  of  hospital  executives.  Surveys  were 
also  made  of  leading  medical  schools  and  hospitals 
in  Japan,  Manchuria,  China  from  Peking  to 
Hong  Kong  and  from  Shanghai  to  Changsha,  the 
Philippines,  Straits  Settlements,  Siam,  and  Indo- 
China.  In  connection  with  public  health  in- 
quiries a  representative  of  the  International 
Health  Board  visited  medical  schools  in  Con- 
stantinople, Beirut,  Cairo,  Bombay,  and  Cal- 
cutta. 

In  the  routine  investigation  of  projects  which 
ask  for  Foundation  aid  a  large  amount  of  valu- 
able data  is  accumulated  in  the  office  files  and 
library.  This  material  forms  a  growing  body  of 
significant  information  about  various  movements 
and  institutions  most  of  which  are  more  or  less 
closely  related  to  public  health  and  medical 
education.  For  example,  during  1921  a  special 
visit  was  made  to  the  Marine  Biological  Labora- 
tory at  Woods  Hole,  Massachusetts,  upon  the 
organization  and  work  of  which  a  report  was  pre- 
pared. 

Sundry  Items  of  Aid  and  Service 

For  twenty  years,  under  the  name  of  the 
Concilium  Bibliographicum,  the  late  Dr.  Herbert 


president's  review  69 

Haviland  Field  maintained  in  Zurich,  Switzer- 
land, a  bureau  of  bibliography  which  provided 
printed  library  cards  and  bound  volumes  of  refer- 
ences in  certain  of  the  biological  and  medical 
sciences.  During  the  war  this  institution  was  so 
seriously  crippled  that  its  continuance  seemed 
impossible.  Pending  a  study  of  the  problem  of 
international  bibliographical  service,  the  Founda- 
tion gave  temporary  aid.  During  the  year  1921 
the  National  Research  Council  of  the  United 
States  made  an  investigation  and  decided  in 
conjunction  with  a  Swiss  society  to  assume  re- 
sponsibility for  the  Concilium.  Toward  capital 
costs  and  for  a  three-year  period  of  maintenance  a 
further  contribution  was  made  by  the  Foundation. 
A  council  of  associations  which  are  interested 
in  hospital  development  has  established  in 
Chicago  a  hospital  library  and  service  bureau. 
This  collects  all  kinds  of  significant  information 
about  hospital  planning,  equipment,  personnel, 
and  administration.  This  clearing  house  fur- 
nishes to  boards  of  trustees,  executives,  and 
others,  authoritative  reports  on  various  phases 
of  the  hospital  problem.  While  attention  has  at 
first  been  centered  on  the  situation  in  the  United 
States,  the  scope  of  the  work  is  being  gradually 
extended  to  include  other  countries.  The  Foun- 
dation has  contributed  to  the  maintenance  of  this 
bureau. 


70        THE  ROCKEFELLER  FOUNDATION 

The  American  Medical  Association  prints  a 
Spanish  edition  of  the  Journal  of  the  American 
Medical  Association  which  circulates  in  Mexico, 
Central  and  South  America,  Spain,  and  the 
Philippine  Islands.  This  edition  so  obviously 
contributed  to  a  wider  knowledge  of  modern 
medicine  and  to  a  better  understanding  between 
the  United  States  and  Spanish-speaking  nations 
that  the  Foundation  has  been  ready  to  share  with 
the  Association  the  burden  of  the  deficit  which  is 
involved  in  its  publication. 

In  answering  the  large  number  of  letters  from 
correspondents  the  officers  of  the  Foundation 
and  its  Boards  try  so  far  as  feasible  to  supply 
useful  information  and  to  offer  practical  sugges- 
tions. It  is  often  possible  in  this  way  to  render 
service  even  when,  as  is  so  generally  the  case,  no 
financial  aid  can  be  given. 

Applications  for  Aid 

Table  1,  covering  the  requests  for  aid  made 
during  the  year  1921,  shows  that  721  formal 
applications  were  dealt  with  by  the  Foundation. 
There  were,  besides,  a  large  number  of  tentative 
inquiries  which  never  reached  the  stage  of  official 
requests.  The  statistics  reflect  the  policy  of 
concentration,  for  the  present  at  least,  upon 
fundamental  projects  of  medical  education  and 
public  health, 


PRESIDENT  S    REVIEW  7 1 

TABLE    1:  APPLICATIONS    FOR   AID   RECEIVED 
AND  ACTED  UPON  DURING   1921 

CLASSIFICATION  OF  APPLICATION    RECEIVED    GRANTED    DECLINED    PENDING 

1.  Public  Health 56  7  49 

2.  Medical  and  nursing  edu- 

cation and  subsidiza- 
tion of  medical  research 
(including  granted  fel- 
lowships)...  . .  132  41  86  5 

3.  General    education     (in- 

cluding educational 
projects  and  research 
other  than  medical) ..  .  71  3  67  1 

4.  Foreign   relief  or  recon- 

struction   21  21 

5.  National   movements   in 

fields  other  than  1  and  2  8  8 

6.  Campaigns   to   influence 

public  opinion 16  16 

7.  Local  churches  and  insti- 

tutions    163  163 

8.  Personal    aid    (including 

loans,     gifts,     medical 

treatment,  education) .  128  128 

9.  Financing  or  promotion 

of  books,  plays,  inven- 
tions, etc 37  36  1 

10.  Investigation,  reward,  or 

purchase     of     alleged 

medical  discoveries  ..  .  51  51 

11.  Miscellaneous 38  1  -37 

Total 721  52  662  7 


Finances  for  1921 

Table  2  gives  a  summary  of  receipts  and 
expenditures  for  the  year  1921. 

The  income  from  invested  funds  was  nearly 
eight  milHons  and  three  quarters.  A  balance  of 
six  millions  was  carried  over  from  1920,  of  which 
four  millions  had  been  pledged.  Likewise  a 
balance  of  seven  and  a  third  millions  was  carried 
forward  into  1922,  of  which  six  and  a  quarter 


^2  THE  ROCKEFELLER  FOUNDATION 

millions  had  been  pledged.  Tables  on  pages  82 
and  83  present  a  summary  of  expenditures  in 
1921  for  all  purposes.  The  total  outstanding 
obligations  of  the  Foundation,  December  31, 
1921,  including  appropriations  already  due,  and 
appropriations  and  pledges  payable  in  1922  and 
future  years,  were  ?23, 219,394.  The  aggregate 
expenditures  of  the  Rockefeller  Foundation  from 
the  time  it  was  chartered  in  1913  up  to  December 
31,  1921,  were  361,081,775.  Thus,  during  its 
existence  the  institution  has  disbursed,  appro- 
priated, or  pledged  a  total  sum  of  384,301,169. 

TABLE  2:  RECEIPTS  AND  DISBURSEMENTS  IN 

1921 

receipts  expenditures 

Balance  from  1920..     36,204,316    Public  Health 32,123,820 

Refunds  on  appropria-  Medical  Education  .       4,111,667 

tions 82,353     Food    Relief — 

Income  during  1921 .  .       8,702,690        Europe 1,000,000 

Miscellaneous 224,748 

Administration 170,123 

37,630,358 
Balance 
Payable  on  1921  and 
prior    year    appro- 
priations 34,032,998 
Available     for     1922 
appropriations 

3,326,003   7,359,001 

314,989,359  314,989,359 

Team-Work  for  World  Health 

The  outlines  of  a  world-wide  campaign  for 
health  are  beginning  to  emerge.  Scientific  re- 
search workers  in  many  national  centers  are  in 


PRESIDENT  S    REVIEW  73 

constant  communication.  Knowledge  is  being 
applied  more  effectively  to  the  problems  in  the 
field.  Governments  are  sending  attaches  of 
hygiene  into  each  other's  territories.  Vital 
statistics  on  an  international  scale  are  being  re- 
ported more  accurately.  Prompt  notification 
of  epidemics  is  being  facilitated.  Outposts 
against  plague  and  other  diseases  are  being  sta- 
tioned and  supported.  Leaders  and  technical 
experts  are  in  training  in  larger  numbers  and 
under  more  favorable  conditions.  Fundamental 
medical  education  is  becoming  more  thorough 
and  more  cosmopolitan.  Popular  knowledge 
about  preventive  medicine  and  personal  hygiene 
is  increasing.  Intercommunications  of  many 
kinds  are  being  improved  and  multiplied.  All 
these  things  are  fostered  by  many  methods  and 
agencies  such  as  working  agreements  between 
governments,  the  Health  Committee  of  the 
League  of  Nations,  and  the  League  of  Red  Cross 
Societies.  It  is  the  purpose  of  the  Rockefeller 
Foundation  and  its  Boards  to  have  a  part  in  this 
world-wide  team-work  for  preventing  disease 
and  bringing  about  improved  conditions  of  health, 
and  thus  "to  promote  the  well-being  of  mankind 
throughout  the  world." 


I* 


THE   ROCKEFELLER    FOUNDATION 
Report  of  the  Secretary 


To  the  President  of  the  RockefeUer  Foundation: 
Sir: 

I  have  the  honor  to  submit  herewith  my 
report  on  the  activities  of  the  Rockefeller  Foun- 
dation for  the  period  January  1,  1921,  to  De- 
cember 31,  1921. 

Respectfully  yours, 

EDWIN   R.   EMBREE, 

Secretary. 


77 


SECRETARY'S  REPORT 

The  review  by  the  President  outlines  the 
poKcies  by  which  the  Rockefeller  Foundation  is 
being  guided  in  its  work,  sketches  its  present  pro- 
gram, and  describes  the  results  aimed  at  and 
accomplished  during  the  year  1921.  The  fol- 
lowing report  depicts  the  organization  and  the 
agencies  through  which  these  results  were 
reached,  and  outlines  the  methods  by  which  the 
programs  of  the  several  departments  were  car- 
ried out. 

Organization 

The  following  are  the  members  and  officers  of 
the  Rockefeller  Foundation  for  1922 : 

MEMBERS 

John  G.  Agar  Vernon  Kellogg 

Wallace  Buttrlck  John  D,  Rockefeller 

John  W.  Davis  John  D.  Rockefeller,  Jr. 

Simon  Flexner  Wickliffe  Rose 

Raymond  B.  Fosdick  Julius  Rosenwald 

Frederick  T.  Gates  Martin  A.  Ryerson 

A.  Barton  Hepburn^  Frederick  Strauss 

Harry  Pratt  Judson  George  E.  Vincent 

EXECUTIVE     COMMITTEE 

George  E.  Vincent,  Chairman 
Wallace  Buttrick  Vernon  Kellogg 

Raymond  B.  Fosdick  Wickliffe  Rose 

Edwin  R.  Embree,  Secretary 


Deceased. 

79 


80  THE   ROCKEFELLER   FOUNDATION 

OFFICERS 

John  D.  Rockefeller,  Jr.  Chairman  Board  of  Trustees 

George  E.  Vincent  President 

Edwin  R.  Embree  Secretary 

Norma  F.  Stoughton  Assistant  Secretary 

L.  G.  Myers  Treasurer 

L.  M.  Dashiell  Assistant  Treasurer 

Robert  H.  Kirk  Comptroller 

Chase  Andrews  Assistant  Comptroller 

Frank  S.  Staley  Office  Manager 

C.  C.  Williamson  Director  of  Information 
Service 

The  Foundation  holds  regular  meetings  in 
February,  May,  and  December.  The  execu- 
tive committee  meets  frequently  during  the 
intervals  to  execute  programs  within  general 
policies  approved  by  the  Trustees.  Twenty- 
two  meetings  of  the  Executive  Committee  were 
held  during  1921. 

Departmental  Agencies 

The  Foundation  accomplishes  its  work  largely 
through  departmental  organizations  that  are 
devoted  to  special  functions,  and  depend  upon 
the  Foundation  for  funds.  These  with  their 
officers  and  members  are: 

INTERNATIONAL    HEALTH    BOARD 

George  E.  Vincent,  Chairman 
Hermann  M.  Biggs  Vernon  Kellogg 

Wallace  Buttrick  T.  Mitchell  Prudden 

Simon  Flexner  John  D.  Rockefeller,  Jr. 

Raymond  B.  Fosdick  Wickliffe  Rose 

Frederick  T.  Gates  Victor  C.  Vaughan 

Edwin  O.  Jordan  William  H.  Welch 

Edwin  R.  Embree,  Secretary 
Florence  M.  Read,  Assistant  Secretary 


secretary's  report  8 1 

Wickliffe  Rose  General  Director 

John  A.  Ferrell,  M.D.  Director  for  the  United  States 

Victor  G.  Reiser,  M.D.        Director  for  the  East 
H.  H.  Howard,  M.D.  Director  for  the  West  Indies 

F.  F.  Russell,  M.D.  Director  of  Public  Health 

Laboratory  Service 

CHINA  MEDICAL   BOARD 

George  E.  Vincent,  Chairman 
Wallace  Buttrick  Vernon  Kellogg 

Simon  Flexner  Harry  Pratt  Judson 

Raymond  B.  Fosdick  John  R.  Mott 

Frederick  L.  Gates  Francis  W.  Peabody 

Frank  J.  Goodnow  John  D.  Rockefeller,  Jr. 

Roger  S.  Greene  W^ickliffe  Rose 

William  H.  Welch 

Edwin  R.  Embree,  Secretary 
Margery  K.  Eggleston,  Assistant  Secretary 

Roger  S.  Greene  Director 

Henry  S.  Houghton  Acting  Resident  Director  in  China 

DIVISION  OF  MEDICAL  EDUCATION 
Richard  M.  Pearce,  M.D.,  General  Director 

Assistance   to   Other   Agencies 

In  addition  to  the  work  carried  out  through  the 
departmental  organizations  described  above,  the 
Rockefeller  Foundation  has  contributed  during 
the  year  to  the  accomplishment  of  work  under- 
taken by  other  and  unaffiliated  organizations. 

On  pages  82  to  83  will  be  found  a  summary  of 
payments  made  by  the  Rockefeller  Foundation 
for  all  purposes  during  the  year  1921.  This 
tabular  summary  outlines,  in  terms  of  expendi- 
tures, the  work  described  in  terms  of  aims  and 
results  in  the  President's  Review.  In  many  in- 
stances these  payments  involved  sums  expended 


82       THE  ROCKEFELLER  FOUNDATION 

on  account  of  appropriations  made  in  former 
years.  On  the  other  hand,  they  represent  in 
some  instances  but  partial  payments  on  many 
of  the  appropriations,  made  during  1921,  which 
will  provide  for  continuing  work  during  succeed- 
ing years.  For  a  full  statement  of  the  finances 
of  the  Foundation,  see  the  Report  of  the  Treas- 
urer, pages  339  to  409. 

TABLE  3:  EXPENDITURES  OF  THE  ROCKE- 
FELLER  FOUNDATION   FOR  THE  YEAR    1921 

I.  PUBLIC  HEALTH 

A.  International  Health  Board 

1.  Regular  program  in  Hookworm,  Malaria,  Yellow  Fever, 

and  County  Health 31,107,604 

2.  Tuberculosis  in  France 438,951 

3.  Fellowships  and  Public  Health  Education 82,696 

B.  Studies  and  Demonstrations 

1.  Mental  Hygiene 86,371 

2.  Hospital  and  Dispensary  Service  and  Studies 84,823 

C.  Schools  of  Public  Health  in  the  United  States 333,375 

32,133,820 

II.  MEDICAL  EDUCATION 

A.  China  Medical  Board 

1.  Regular  program  of  aid  to  Medical  and  Pre-Medical 

Schools  and  to  Hospitals 3419,705 

2.  Peking  Union  Medical  College 

(a)  Land  and  Buildings 1,114,973 

(b)  Operation 393,349 

3.  Fellowships  and  Scholarships 27,423 

B.  London  Medical  Center 826,296 

C.  Canadian  Medical  Program 1,158,853 

D.  Central  Europe:  Journals  and  Apparatus 43,813 

E.  Pasteur  Institute 30,000 

F.  University  of  Chicago — Interest  on  Pledge 43,739 

G.  Fellowships  and  Scholarships 17,574 

H.  Brazil 12,169 

I,     Commissions  and  Studies  of  Medical  Education 31,367 

34,119,261 


secretary's  report  83 

III.  MISCELLANEOUS 

(Chiefly  payments  on  previous  pledges) 

A.  American   Academy   in   Rome — (Payments   on    10-year 

pledge  made  in  1914) 310,000 

B.  American     Medical     Association — (Toward     publishing 

Spanish  Edition  of  Journal) 8,000 

C.  American   Relief  Administration — (Child   Feeding  Pro- 

gram in  Europe) 1,000,000 

D.  Committee  on  Reference  and  Counsel  of  Annual  Foreign 

Missions  Conference  of  North  America 35,000 

E.  Common  Service  Committee — (For  Correlation  of  Service 

of  Health  Agencies) 19,304 

F.  Concilium  Bibliographicum,  Zurich 21,461 

G.  National  Information  Bureau — (For  Membership  for  year 

1921) 1,000 

H.  National  Research  Council — (Fellowships  in  Physics  and 

Chemistry) 60,574 

I.     New  York  Association  for  Improving  the  Condition  of  the 

Poor— (Payment  on  10-year  Pledge  made  in  1914) 20,000 

J.     Rockefeller  Institute  for  Medical  Research  and  Johns 

Hopkins  University — (For  Special  Investigations) 5,750 

K.  Grand  Chenier  Bird  Refuge — Taxes  and  Expenses 7,713 

L.    Final  Payments  on  Work  begun  in  connection  with  War 

Emergency 2,682 

$1,191,484 


IV.  ADMINISTRATION 

A.  Maintenance  of  Executive  Offices  and  Treasurer's  Office        3170,123 

B.  Furniture  and  Fixtures,  and  Books 15,669 


3185,792 
37.630,357 
Funds  and  Property 

Asof  December  31,  1921 

PRINCIPAL  FUNDS 

General  Fund 3171,204,624 

Reserve  (excess  of  amounts  received  from  sales 
and  redemption  of  securities  over  their  book 
value,  set  aside  to  offset  future  losses) 3,190,533 

Special  Funds: 

Gifts  of  John  D.  Rockefeller 337,000 

Gifts  of  Laura  S.  Rockefeller 49,300 

Henry  Sturgis  Grew  Memorial  Fund 25,000 

Arthur  Theodore  Lyman  Endowment 5,500  116,800 

3174,511,957 


84       THE  ROCKEFELLER  FOUNDATION 

LANDS,  BUILDINGS,  AND  EQUIPMENT 
In  China:  Medical  School  Lands,  Buildings,  and 

Equipment 38,631,833 

In   New  York:   Furniture  and  Equipment  of 

Offices 34,980 

38,666,813 

UNDISBURSED  INCOME 

General  Income  (For  offsetting  liabilities  see 
below) 37,359,001 

Special  Income  Accounts: 

Estate  Laura  S.  Rockefeller 365 

Henry  Sturgis  Grew  Memorial 4,083 

Arthur  Theodore  Lyman  Endowment 714  4,862 

37,363,863 

UNPAID  APPROPRIATIONS  AND  PLEDGES 

Balance  due  on  appropriations  payable  in  1921 

and  prior  years 34,032,998 

Appropriations    and    pledges    which    become 
effective  in  1922  and  following  years: 

1922 36,280,746 

1923 4,619,892 

1924 3,460,067 

1925- 2,596,191 

1926 2,229,500    319,186,396 

323,219,394 


INTERNATIONAL  HEALTH  BOARD 
Report  of  the  General  Director 


INTERNATIONAL  HEALTH  BOARD 

Report  of  the  General  Director 

To  the  President  of  the  Rockefeller  Foundation : 

Sir: 

I  have  the  honor  to  submit  herewith  my  report 
as  General  Director  of  the  International  Health 
Board  for  the  period  January  1,  1921,  to  Decem- 
ber 31,  1921. 

Respectfully  yours, 

WICKLIFFE  ROSE, 

General  Director. 


87 


INTERNATIONAL  HEALTH  BOARD 
OFFICERS  AND  MEMBERS 

George  E.  Vincent,  Chairman 

WiCKLiFFE  Rose,  General  Director 

Hermann  M.  Biggs 

Wallace  Buttrick 

Simon  Flexner 

Raymond  B.  Fosdick 

Frederick  T.  Gates 

Edwin  O.  Jordan 

T.  Mitchell  Prudden 

John  D.  Rockefeller,  Jr. 

Frederick  Strauss 

Victor  C.  Vaughan 

William  H.  Welch 


Edwin  R.  Embree,  Secretary 
Florence  M.  Read,  Assistant  Secretary 


88 


PERSONNEL  OF  STAFFS  DURING  192  P 

ADMINISTRATIVE   STAFF 

WiCKLiFFE  Rose,  General  Director 
John  A.  Ferrell,  M.D.,  Director  for  the  United  States 
Victor  G.  Heiser,  M.D.,  Director  for  the  East 
Hector  H.  Howard,  M.D.,  Director  for  the  West  Indies 
L.  W.  Hackett,  M.D.,  Associate  Regional  Director  {for 

Brazil) 
Frederick  F.  Russell,  M.D.,  Director  of  Public  Health 

Laboratory  Service 

FIELD  STAFF 

HOOKWORM 

Australia  (including  Papua  and  late  W.  A.  Sawyer 

German  New  Guinea)  S.  M.  Lambert' 

C.  N.  Leach 
W.  C.  Sweet  2 

Brazil  L.  W.  Hackett 

G.  K.  Strode 
Paes  de  Azevedo  (resigned) 

Alagoas  F.  L.  Soper  (survey) 

Alan  Gregg 

Espirito  Santo  G.  K.  Strode 

Alan  Gregg  (survey) 
J.  H.  Janney^  (survey) 

Pernambuco  Alan  Gregg 

F.  L.  Soper 

Rio  de  Janeiro  G.  K.  Strode 

Rio  Grande  do  Sul  Alan  Gregg 

F.  L.  Soper 

Santa  Catharina  Alan  Gregg 

F.  L.  Soper 

Sao  Paulo  G.  K.  Strode 

British  North  Borneo  C.  H.  Yeager 

1  Personnel  employed  by  Government  in  co-operative  work  not  liste4. 
^  Special  Staff  Member. 

39 


90  THE  ROCKEFELLER 

British  Solomon  Islands  (survey) 
Ceylon 


Colombia 
Costa  Rica 


Dutch  Guiana 
Guatemala 

India 

Jamaica 
Nicaragua 
Panama 
Porto  Rico 
Salvador 

SlAM 

Trinidad 


COUNTY   HEALTH   WORK 

Alabama 

[ndiana 
Kansas 
Kentucky 


FOUNDATION 

S.  M.  Lambert^ 

W.  P.  Jacocks 
G.  G.  Hampton 

C.  N.  Leach 

S.  A.  Winsor  (resigned) 

F.  A.  Miller 

Louis  Schaplro 

J.  E.  Elmendorf,  Jr. 

W.  C.  Hausheer 

E.  I.  Vaughn 

J.  E.  Elmendorf,  Jr. 

J.  F.  Kendrick 

G.  P.  Paul 

B.  E.  Washburn 

D.  M.  Molloy 

F.  C.  Caldwell 
R.  B.  Hill 

C.  A.  Bailey 

M.  E.  Barnes 
H.R.  O'Brien  1 

G.  C.  Payne 
W.  C.  Hausheer 
J.  L.Rice  1 

IN  UNITED  STATES 

F.  W.  Dershimer 

A.  L.  McKay  (resigned) 

G.  P.  Paul 
A.  J.  Warren 

P.  W.  Covington 


Special  Staff  Member. 


INTERNATIONAL    HEALTH    BOARD 


91 


Louisiana 
New  Mexico 
Texas 
Alabama 
Arkansas 

Louisiana 
Mississippi 

Missouri 
Nicaragua 
North  Carolina 

Porto  Rico 
South  Carolina 
Tennessee 

Texas 

Virginia 


MALARIA 


P,  W.  Covington 
Hugo  Muench,  Jr. 

J.  F.  Docherty 
D.  B.  Wilson 

A.  P.  Harrison  ^ 


E.  B.  Johnson  *  (resigned) 
William  Ropes  ^ 

P.P.  Gilbert! 

L.  G.  Hastings  ^  (resigned) 

William  Ropes  ^ 

L.  J.  Petrit2 

C.  C.  Bassi 
J.  L.Clarke  1 

M.  F.  Boyd 

F.  E.  Hulsei 

H.  A.  Taylor 

C.  E.  Buck  1  (resigned) 

J.  J.  Mieldazis  ^ 

H.  W.Green » 

J.J.  Mieldazis » 

H.  A.  Johnson  * 
N.  H.  Rector  1 

E.  H.  Magoon  ^ 
Geo.  Parker ! 

E.  H.  Gage  ^  (resigned) 


YELLOW  FEVER 

Yellow  Fever  Advisory  Council^ 

Henry  R.  Carter,  M.D.,  Assistant  Surgeon  General,  United  States 
Public  Health  Service 


1  Special  Staff  Member. 

2  Not  Staff  Members;  appointed  to  serve  in  an  advisory  capacity. 


92        THE  ROCKEFELLER  FOUNDATION 

Juan  Guiteras,  M.D.,  Secretary,  Department  of  Health  and  Chari- 
ties, Cuba 
Hideyo  Noguchi,  M.D.,  Rockefeller  Institute  for  Medical  Research 
Joseph  H.  White,  M.D.,^  Assistant  Surgeon  General,  United  States 
Public  Health  Service 

Mexico  and  Central  America  T.  C.  Lyster  ^ 

British  Honduras  E.  I.  Vaughn 

Guatemala  E.  I.  Vaughn 

H.  K.  Marshall  ^  (resigned) 
T.  F.  Botelloi 

Honduras  E.  I.  Vaughn 

C.  A.  Bailey 

Mexico  J.  H.White  1 

B.W.Caldwell* 
M.  E.  Connor 
W.  M.  Monroe 

E.  I.  Vaughn 
Nicaragua                                                  D.  M.  Molloy 
Salvador                                                     C.  A.  Bailey 

W.  H.  Davies  ^  (resigned) 

Peru  J.  H.White  i 

TUBERCULOSIS 

France  L.  R.  Williams  ^ 

Alexander  Bruno  * 

F.  Elisabeth  Crowell  * 
B.  L.  Wyatt^  (resigned) 

SPECIAL 

Australia — Public  Health  Administration 

A.  J.  Lanza ' — Lent  to  Department  of  Health  for  two  years  to  assist 

in  organization  of  Department  of  Industrial  Hygiene 
F.  F.  Longley' — Lent  to  Department  of  Health  for  two  years  to 

assist  in  organization  of  Department  of  Sanitary  Engineering 

Brazil — County  Health  Work 
J.  H.  Janney  ^ 

Public  Health  Nursing  Service 
Mrs.  Ethel  Parsons  ^ 

School  of  Hygiene  and  Public  Health,  Sao  Paulo 
W.  G.  Smillie,  Director  and  Professor  of  Hygiene 


» Special  Staff  Member. 


INTERNATIONAL    HEALTH    BOAkD  93 

China — Special  Service 

J.  B.  Grant — Lent  to  Peking  Union  Medical  College  as 
Associate  Professor  of  Hygiene  and  Public  Health 

Czechoslovakia — Public  Health  Administration 
S.  M.  Gunn  i 

Paraguay — Public  Health  Survey 
L.  W.  Hackett 

Philippine  Islands — Public  Health  Survey 
V.  G.  Heiser 

ON   LEAVE 

(for  whole  or  part  of  year) 
W.  T.  Burres 
S.  T.  Darling ' 
H.  H.  Howard 
J.  J.  Mieldazis » 
Louis  Schapiro 

AT  HOME  OFFICE 

C.  W.  Wells  (in  charge  of  fellowships) 
J.  L.  Hydrick 

ENGAGED  IN  SPECIAL  STUDY  (Johns  Hopkins  School  of 
Hygiene  and  Public  Health) 

S.  T.  Darling  i 
J.  B.  Grant 
Louis  Schapiro 


IN   TRAINING 

Australia 

C.  N.  Leach 
W.C.  Sweet  1 

Brazil 

J.  H. Janneyi 

Ceylon 

C.  N.  Leach 

Mexico 

W.  M.  Monroe 

Siam 

H.R.  O'Brien  1 

Tennessee 

H.  A.  Johnson  * 
N.H.  Rector  1 

'Special  Staff  Member. 


PROMOTING  HEALTH  IN  MANY  LANDS 

The  period  of  three  years  since  the  armistice 
has  been  one  of  unprecedented  activity  in  gov- 
ernment organization  for  war  on  disease:  new 
national  health  services,  including  new  ministries 
of  health,  have  been  created  in  England,  France, 
Australia,  Czechoslovakia,  Poland,  and  the 
kingdom  of  the  Serbs,  Croats,  and  Slovenes; 
in  other  countries  national  and  state  services 
have  been  reconstituted  with  enlarged  powers 
and  resources;  public  funds  for  health  purposes 
have  been  enormously  increased;  and  the  call  for 
qualified  men  Is  being  met  by  the  establishment 
of  institutions  to  provide  the  training  required. 
During  the  year  1921  the  International  Health 
Board  has  shared  in  activities  designed  to  pro- 
mote this  movement  in  sixty-three  states  and 
countries  throughout  the  world. 

I 

International  Co-operation  in  Yellow  Fever  Control 

There  are  important  public  health  functions 
which  are  essentially  international  in  character. 
No  nation  acting  alone  can  perform  them. 
Among  these  is  the  control  of  the  great  epidemic 
plagues  of  which  yellow  fever  is  a  conspicuous 
example.     For  more  than  200  years  prior  to  the 

95 


96 


THE  ROCKEFELLER  FOUNDATION 


work  of  Reed  and  his  colleagues  at  Havana  the 
tropical  and  semi-tropical  regions  of  the  Americas 
had  been  subject  to  devastating  invasions  of  this 
disease.  During  this  period  appalling  epidemics 
swept  repeatedly  over  the  coastal  regions  of 
Brazil  as  far  south  as  Rio  de  Janeiro,  up  the 
Amazon  valley,  along  the  Caribbean  littoral, 
throughout  the  West  Indies,  Central  America, 
Mexico,  and  the  southern  United  States,  and  over 
the  west  coast  of  America  from  Callao  in  Peru  to 
Mazatlan  in  Mexico.  The  infection  had  crossed 
the  sea  to  West  Africa;  had  apparently  become 
endemic  there;  and  had  appeared  from  time  to 
time  in  places  as  remote  from  its  original  source 
as  England,  France,  Spain,  and  Italy.  No  coun- 
try had  the  power  of  self-defense.     Despite  the 


Fig.  12. — Yellow  fever  map  of  the  Western  Hemisphere.  The  shading 
indicates  localities  in  which  one  or  more  cases  of  the  disease  appeared. 
Compare  1921  with  1900.  The  disease  is  steadily  retreating  as  the  con- 
certed attack  progresses 


INTERNATIONAL  HEALTH  BOARD       97 

most  rigid  quarantine  regulations  the  infection 
overran  national  boundaries,  decimating  popula- 
tions, paralyzing  industry  and  trade,  and  holding 
the  people  of  these  regions  in  a  state  of  perpetual 
dread. 

Reed  and  his  commission  discovered  the  key  to 
yellow  fever  control.  By  international  concert 
of  effort  the  infection,  so  far  as  the  Western 
Hemisphere  is  concerned,  has  been  pretty  well 
delimited  and  its  boundaries  are  being  steadily 
driven  in  (see  Fig.  12,  page  96). 

Fighting  an  Epidemic  in  Peru 

The  Pacific  coast  from  Panama  to  Callao  in 
Peru  is  treated  as  a  unit.  Since  the  days  of 
Gorgas  in  Panama  a  low  Stegomyia  index  steadily 
maintained  has  protected  that  community 
against  reinvasion.  Recent  inspection  in  Buena- 
ventura, Colombia,  indicates  satisfactory  condi- 
tions with  no  traces  of  danger  in  that  port  of 
entry.  No  case  has  been  reported  from  Ecuador 
since  May,  1919.  Dr.  Pareja,  local  health  officer, 
is  holding  the  mosquito  index  in  Guayaquil  below 
the  danger  point  as  a  safeguard  against  reinva- 
sion from  Peru. 

The  scene  of  active  operations  on  this  coast 
during  1921  has  been  in  Peru.  At  some  time 
preceding  its  elimination  from  Ecuador  in  1919  it 
had  crossed  the  border  into  Peru  and  had  become 


98 


THE  ROCKEFELLER  FOUNDATION 


well  established  there  before  being  recognized  as 
yellow  fever.  Because  of  limited  funds  and  lack 
of  trained  personnel,  first  efforts  at  control  were 
on  an  inadequate  scale.  By  March,  1920,  the 
disease  had  appeared  in  serious  epidemic  form 

over  a  wide  region 
in  the  department 
of  Piura  and  is 
estimated  to  have 
numbered  about 
6,000  cases  before 
its  final  suppres- 
sion in  August  of 
that  year.  Again 
the  infection  es- 
caped. Just  be- 
fore its  final  ex- 
tinction in  Piura 
it  had  crossed  a 
desert  zone  which  had  been  depended  upon 
to  protect  the  region  farther  south,  and  under 
the  guise  of  "acute  malaria"  had  established 
itself  in  the  department  of  Lambayeque.  With 
a  dense,  non-immune  population  and  an  ex- 
tremely high  Stegomyia  index — from  60  to 
100  per  cent — it  spread  with  great  rapidity. 
From  Lambayeque  the  epidemic  extended  south 
through  the  department  of  Libertad  with  an 
estimated  total  of  from  10,000  to  15,000  cases. 


I TCLLOW  FEVER  AREAS.  I»2I 


^ARMY  CONTINGENT  "CORDON 


Fig.  13. — Scene  of  the  violent  yellow  fever 
epidemic  in  Peru  during  1921 


INTERNATIONAL    HEALTH    BOARD  99 

Controlling  the  Epidemic  with  Fish 

In  February,  1921,  Government  placed  Doctor 
Henry  Hanson  in  charge  of  the  campaign  with 
full  authority.  The  International  Health  Board 
was  called  upon  to  supplement  available  funds. 
Competent  local  physicians  were  enlisted;  a 
limited  number  of  trained  inspectors  were 
brought  down  from  Panama;  and  as  rapidly  as 
possible  systematic  operations  were  organized  to 
cover  not  only  the  infected  area  but  also  a  con- 
siderable barrier  zone  lying  south  of  the  region  of 
known  infection.  All  effort  was  centered  on  the 
control  of  Stegomyia  breeding. 

Here  as  in  Guayaquil  the  result  was  finally  ac- 
complished by  enlisting  two  local  species  of  fish 
to  devour  the  eggs  and  larvae  of  the  mosquito. 
An  attempt  in  the  beginning  of  the  campaign  to 
teach  the  people  to  prevent  breeding  on  their  own 
premises  failed.  Everything  had  to  be  done  by 
the  mosquito  squad.  Effort  to  keep  water  con- 
tainers covered  was  equally  unsuccessful.  Strain- 
ing the  water  (which  in  that  dry  country  was  too 
precious  to  be  turned  out)  involved  an  amount  of 
labor  that  made  it  impracticable  for  a  region  so 
vast.  It  was  found  that  by  distributing  fish — 
two  to  four  small  fish  to  a  container  holding  ten 
to  fifteen  gallons — the  problem  was  simplified  by 
about  75  per  cent,  with  a  lower  resulting  mosquito 
index  than  it  had  been  possible  to  get  in  any 


100      THE  ROCKEFELLER  FOUNDATION 

Other  way.  The  750,000  fish  distributed  in 
this  drive  conquered  the  epidemic.  The  last 
case  was  reported  from  Libertad  on  July  16. 

No  case  has  been  reported  from  Piura  since 
August,  1920,  and  there  has  been  no  known  case 
anywhere  in  Peru  since  July,  1921.  So  vast, 
however,  is  the  region  covered  by  the  epidemic 
and  so  often  has  the  infection  lingered  unrecog- 
nized in  remote  communities  that  one  would  not 
venture  at  this  time  to  declare  the  country  free. 
As  a  precaution  against  the  reappearance  of  the 
disease  the  drive  against  Stegomyia  is  to  be 
continued  up  to  May,  1922.  It  will  cover  the 
entire  region  from  Ecuador  to  Callao — a  distance 
of  500  miles — and  from  the  sea  back  to  the 
mountains — a  zone  varying  in  width  from  fifty  to 
seventy-five  miles.  If  up  to  that  time  no  case 
shall  have  appeared  the  forces  will  be  demo- 
bilized. 

Yucatan  a  Historic  Center  of  Infection 

As  Guayaquil  for  more  than  seventy-five  years 
had  served  as  the  endemic  focus  from  which  yel- 
low fever  has  spread  from  time  to  time  over 
the  Pacific  coast,  so  Merida,  in  Yucatan,  has 
been  regarded  by  sanitarians  as  an  important 
seed-bed  of  long  standing  from  which  the  infec- 
tion has  been  distributed  repeatedly  throughout 
Mexico  and   the   Central    American   countries. 


Fig.  15. — ^A  small  model  showing  the  types  of  water  con- 
tainers used  about  the  dwellings  in  Merida,  Yucatan. 
The  exhibition  of  this  model,  made  of  scrap  tin  by  an  in- 
spector in  his  spare  time,  did  much  to  arouse  the  interest 
of  householders  in  preventing  mosquito  breeding 


Fig.  16. — Shallow,  driven  tubular  well  for  preventing 
Stegomyia  breeding,  Corinto,  Nicaragua.  The  placing  of 
fish  in  the  open  wells  of  this  town  freed  the  water  of 
larvae,  but  frequent  careful  inspection  was  necessary. 
The  driven  well  has  solved  the  problem.  A  small  block 
and  platform  of  concrete  are  adequate  to  protect  it 


INTERNATIONAL  HEALTH  BOARD      IO3 

Recent  archeological  studies  in  Yucatan  have 
given  the  subject  an  added  interest.  They 
bring  to  light  the  records  of  devastating  yellow 
fever  epidemics  in  the  Maya  cities  of  this  densely 
populated  region  antedating  the  Spanish  inva- 
sion. It  is  to  this  cause  Dr.  Spinden^  attributes 
the  depopulation  of  these  ancient  cities  and  the 
decay  of  Maya  civilization  in  the  lowlands  bor- 
dering the  Gulf.  It  is  one  of  the  great  plagues 
of  the  early  Spanish  records.  Throughout  mod- 
ern times  it  has  remained  a  scourge  of  this  region, 
with  Merida  as  an  important  source  of  infection. 
Within  the  last  few  years  the  disease  has  ap- 
peared in  epidemic  form  throughout  eastern 
Mexico,  on  the  Mexican  Pacific  coast  from 
Mazatlan  to  Guatemala,  in  Guatemala,  Salva- 
dor, Nicaragua,  Honduras,  and  British  Hon- 
duras. 

Winning  by  Team-Play 

No  one  of  these  countries  acting  alone  could 
protect  itself.  The  effort  was  much  like  at- 
tempting to  empty  a  spring  with  a  spoon. 
Guatemala,  for  example,  suppressed  an  epidemic 
which  had  spread  to  sixteen  communities  on  the 
Pacific  coast  in  1918,  only  to  have  the  infection 
reintroduced  the  following  year.  Now,  by  inter- 
national co-operation,  control  measures  over  this 

^Yellow  Fever — First  and  Last.    By  Herbert  J.  Spinden.     World's 
Work,  December,  1921,  p.  169-181, 


I04      THE  ROCKEFELLER  FOUNDATION 

entire  region  are  being  administered  as  a  unit. 
Active  operations  in  each  country  are  being  car- 
ried out  by  a  yellow  fever  commission  created  by 
special  decree,  under  the  national  departments  of 
health  and  clothed  with  authority.  The  neces- 
sary unity  of  effort  is  secured  by  the  simple  de- 
vice of  giving  the  International  Health  Board 
representation  on  each  of  these  commissions. 

This  united  drive  opened  in  Salvador,  Nicara- 
gua, Guatemala,  and  Honduras  in  1920;  in  Mex- 
ico in  January,  1921;  and  in  British  Honduras 
in  August,  1921.  The  Mexican  department  of 
health  had  been  active  on  its  own  account  during 
the  previous  year  and  had  done  much  to  reduce 
the  severity  of  the  epidemic  that  had  swept  over 
the  eastern  part  of  that  country  from  Yucatan  to 
Tampico.  In  this  campaign  as  in  Peru  effort  is 
centered  on  the  control  of  Stegomyia  breeding. 
The  problem  has  been  enormously  simplified  by 
permanently  sealing  the  domestic  tanks  and  by 
using  larvae-devouring  fish  in  all  containers  hold- 
ing sufficient  water  to  support  fish  life.  By  the 
introduction  of  these  two  simple  devices  in 
Guayaquil  in  1919  Dr.  Connor  had  been  able  to 
reduce  his  field  staff  for  a  given  area  from  139 
men  to  twenty  men.  Experience  during  1921 
abundantly  confirms  the  result. 

War  on  the  mosquito  is  conquering  the  disease. 
At  the  present  time  there  seems  to  be  no  yellow 


INTERNATIONAL    HEALTH    BOARD  IO5 

fever  in  Merlda  or  anywhere  in  Yucatan.  The 
important  base  ports  of  Campeche,  Vera  Cruz, 
Tuxpan,  and  Tampico  are  being  held  with  a 
Stegomyia  index  sufficiently  low  to  prevent  the 
transmission  of  infection  within  these  communi- 
ties: and  from  these  centers  control  measures  are 


•Towns  in  which  there  was  Yellow  Fever  during  1921 


Fig.  17. — Map  of  Mexico  and  Central  America  showing  towns  visited 
by  yellow  fever  in  1921 

being  gradually  extended  to  the  outlying  com- 
munities. A  smouldering  infection  still  remains 
in  a  back-country  region  about  Papantla;  in  a 
densely  populated  agricultural  valley  west  from 
Cosamaloapan  in  the  southern  part  of  the  state  of 
Vera  Cruz;  and  along  the  Gulf  coast  in  British 
Honduras  from  Belize  to  Santa  Cruz  de  Bravo  in 
Quintana  Roo.     Within  recent  months  system- 


io6 


THE  ROCKEFELLER  FOUNDATION 


atic  mosquito  control  has  been  undertaken  on  the 
Mexican  Pacific  coast,  where  the  infection  seems 
to  have  been  appearing  from  time  to  time  for  the 

last  three  years  over 
a  vast  region  from 
Manzanillo  to  Mazat- 
lan.  These  remain- 
ing areas  of  infection 
should  involve  no  par- 
ticular difficulties.  No 
case  of  yellow  fever 
has  been  reported 
from  Nicaragua,  Sal- 
vador, Guatemala,  or 
Honduras  for  more 
than  ten  months. 
The  number  of  cases 
reported  from  Mexico 
and  Central  America 
for  1920  was  710;  for 
1921  the  total  num- 
^.     ,„    ,,  „      ,  .      ber  of  reported  cases 

rig.    18. — Yellow  fever   cases   in  ^ 

Mexico  and  Central  America,  1920  is  145,  aS  shown  m 
and   1921.     Control  effort  is  being 

continued  to  stamp  out  the  infection  Fig.    18. 


700 

600 
ce 

'^    500 

o 

d 

Ui 

fe    400 

o 

^    300 

s 

i     200 

100 

• 

■ 

NUMBER 
OF  CASES 

710 

145 

YEAR 

1920 

1921 

Government  Continuing  the  Attack  in  Brazil 

The  other  remaining  center  of  yellow  fever  on 
the  Western  Hemisphere  is  in  Brazil.  The  in- 
fection, formerly  covering  the  entire  coast  from 


INTERNATIONAL    HEALTH    BOARD  I07 

Rio  de  Janeiro  north  and  up  the  Amazon  valley 
to  Yquitos  in  Peru,  seems  now  to  be  confined  to  a 
narrow  coastal  zone  from  Pernambuco  to  Bahia. 
These  two  cities  are  presumably  the  endemic  foci. 
In  April  an  epidemic  was  reported  in  the  state  of 
Bahia.  It  had  apparently  been  in  progress  for 
months,  had  spread  over  a  considerable  area,  and 
numbered  from  400  to  500  cases.  Cases  were  re- 
ported also  from  Natal  in  Rio  Grande  do  Norte, 
from  Porto  Calvo,  Alagoas,  and  from  the  district 
between  Alagoas  and  Pernambuco. 

Until  the  last  vestige  of  yellow  fever  has  been 
stamped  out  here  this  region  must  be  recognized 
as  a  constant  menace  to  the  rest  of  Brazil,  to 
the  coasts  of  Venezuela  and  Colombia,  and  to 
the  neighboring  West  Indies.  Freedom  from  the 
disease  for  a  considerable  period  has  given  op- 
portunity for  the  development  in  these  countries 
of  a  non-immune  population.  A  reinvasion  at 
this  time  would  probably  be  vastly  more  disas- 
trous than  it  could  have  been  ten  years  ago.  The 
Brazilian  national  department  of  health  is  con- 
tinuing the  fight  against  the  disease  in  and  about 
Pernambuco  and  Bahia,  and  has  ample  funds 
for  the  purpose. 

Yellow  Fever  Commission  to  West  Africa 

In  1920  the  Board  sent  a  commission  to  West 
Africa  to  determine  if  possible  whether  yellow 


I08      THE  ROCKEFELLER  FOUNDATION 

fever  is  present  in  that  region,  and  if  so,  whether 
control  measures  would  be  feasible.  The  com- 
mission visited  the  Belgian  Congo,  Dahomey, 
Gold  Coast,  Northern  Nigeria,  Senegal,  Sierra 
Leone,  and  Southern  Nigeria;  saw  no  case  of  yel- 
low fever;  conferred  with  medical  authorities  and 
examined  many  records ;  found  strong  indications 
of  the  presence  of  the  infection  within  recent 
years;  and  recommended  that  a  second  commis- 
sion be  sent  out  prepared  to  stay,  if  necessary,  for 
a  period  of  two  years  for  a  more  extended  in- 
vestigation— this  to  include  a  laboratory  study 
of  the  suspected  fevers  of  the  region.  The  Board 
has  approved.  The  fixing  of  the  date  of  depar- 
ture for  this  second  commission  must  await  the 
necessary  arrangements  with  governments  con- 
cerned, the  special  training  of  laboratory  per- 
sonnel, and  the  development  of  operations  in 
other  fields  making  possible  the  release  of  clinical 
specialists  for  the  staff. 

The  Noguchi  Vaccine  and  Serum 

Killed  cultures  of  Leptospira  icteroides  as  a 
protective  vaccine  against  yellow  fever  were  first 
prepared  and  tested  by  Noguchi  in  Guayaquil 
in  1918.  The  use  of  the  vaccine  with  laboratory 
animals  had  demonstrated  its  value  in  producing 
immunity.  During  the  year  1920  it  was  used  on 
a  considerable  scale  on  human  subjects  in  Mexico 


INTERNATIONAL    HEALTH    BOARD  I09 

and  Central  America,  and  the  test  was  continued 
during  the  year  1921  in  these  countries  and  in 
Peru.  The  cumulative  results  of  the  two  years' 
experience  tend  to  confirm  the  earlier  indications. 
To  take  a  single  striking  example,  Dr.  Hanson 
vaccinated  200  non-immune  soldiers  in  Lam- 
bay  eque,  Peru,  and  200  civilians  in  Paijan.  They 
went  through  a  severe  epidemic  without  a  case 
among  them.  Continued  tests  of  the  therapeutic 
serum  tend  also  to  support  the  earlier  results. 
When  administered  in  the  early  stages  of  the 
disease  it  seems  greatly  to  increase  the  chances 
of  recovery. 

II 

Extending  the  Front  against  Malaria 

Despite  the  economic  depression  which  hit  the 
Southern  States  with  extreme  severity,  the  fight 
against  malaria  has  been  maintained  and  steadily 
extended.  A  series  of  field  experiments  carried 
out  in  previous  years  had  shown  that  malaria 
control  in  towns  having  a  population  of  1,000  or 
over  and  representing  average  conditions  in  these 
states  is  a  paying  investment.  Effort  was  made 
during  the  year  1920  to  drive  this  fact  home 
throughout  the  more  heavily  infected  region. 
By  joint  arrangement  state  departments  of 
health,    local   communities,   the  United    States 


no 


THE  ROCKEFELLER  FOUNDATION 


Public  Health  Service,  and  the  International 
Health  Board  shared  in  carrying  out  demonstra- 
tions in  fifty-two  towns  in  ten  states  during  1920. 
In  some  communities  control  was  effected 
mainly  by  the  top  minnow  {Gamhusia  affinis). 

Malaria  cases  in  these 
communities  were  re- 
duced from  30  to  98 
per  cent  at  an  aver- 
age per  capita  cost  of 
about  seventy-eight 
cents.  These  results 
graphically  exhibited 
were  given  wide  pub- 
licity. The  effect  has 
been  the  creation  of 
a  sustaining  and  even 
aggressive  public 
opinion  which  would 
seem  to  guarantee 
the  permanency  of 
the  work. 

During  the  year 
1921  the  service  has 
been  consolidated 
and  extended.  State  and  local  funds  have  been 
increased.  Malaria  control  is  being  made  an 
integral  part  of  the  county  health  program 
and  the  states  are  assuming  the  responsibility 


Fig.  19. — ^What  malaria  has  cost  the 
towns  of  Bamberg  and  Chester,  South 
Carolina,  during  the  years  1918  to 
1921,  inclusive,  in  the  form  of  wages 
lost,  doctors'  bills,  and  medicines. 
Combined  population,  7,768.  Con- 
trol measures  instituted  in  both  towns 
in  1920  have  strikingly  reduced  this 
economic  loss 


INTERNATIONAL    HEALTH    BOARD 


III 


for  its  central  supervision.  Six  states — Ala- 
bama, Arkansas,  Mississippi,  Missouri,  South 
Carolina,  and  Virginia — have  provided  central 
administrative  budgets  and  are  appointing  spe- 
cially trained  personnel  for  the  purpose.    To  meet 


1750 

1500 

1250 

"  "W> 

i    750 

SOO 

1 

1 

Beginning  o( 
Control  Operations 
i 

250 

1 

1 

ll 

II 

1 

lllll.llll.. 

NIIMRFR 
OF  CALLS 

103 
137 
184 
368 
612 

1404 
1592 
1802 
851 
463 
176 

SSSg§^SS§Ss5 

KSss-ssjeasSR 

MONTH 

JAN. 

FEB. 

MAR. 

APR. 

MAY 
JUNE 
JULY 

AUG. 
SEPT. 

OCT. 

NOV 

DEC. 

JAN. 
FEB. 
MAR. 
APR. 
MAY 
JUNE 
JULY 
AUG. 
SEPT. 
OCT. 
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DEC. 

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FEB. 
MAR. 
APR. 
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JUNE 
JULY 

Aua 

SEPT. 
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YEAR 

■'" 

1920 

1 

Fig.  20. — Reduction  in  physicians'  calls  for  malaria  in  Groveton  and 
South  Groveton,  Texas.  Combined  population,  2,500.  Control  opera- 
tions beginning  on  April  1,  1920,  strikingly  checked  the  development  of 
malaria  cases  during  the  remainder  of  1920  and  in  1921  kept  the  number 
of  cases  at  a  mere  fraction  of  the  number  in  1919,  -which  was  typical  of 
conditions  in  pre-control  years 

the  increasing  demand  for  sanitary  engineers  and 
physicians  who  have  had  special  training  in  this 
field,  the  Board  has  undertaken  to  maintain  a 
considerable  reserve  corps  through  a  period  of 
apprenticeship.  On  completion  of  their  training 
they  are  taken  into  federal,  state,  or  county 
service. 


112      THE  ROCKEFELLER  FOUNDATION 

Intensive  demonstrations  have  been  under- 
taken during  1921  in  twenty-six  additional  towns. 
In  a  number  of  communities — as  in  Texas  for 
example — the  municipal  governments  have  pro- 
vided the  entire  cost  of  the  work  save  that  of 
general  supervision.  For  typical  results  see 
Figs.  19  and  20,  pages  110  and  111, 

Malaria  Control  on  a  County-Wide  Scale 

Field  experiments  in  which  the  Board  has 
shared  hitherto  have  had  for  their  object  the 
testing  of  separate  control  measures:  mosquito 
control  in  small  towns;  mosquito  control  in  a 
typical  rural  community;  quinine  for  sterilizing 
the  blood  of  the  infected;  protection  by  the 
screening  of  houses.  These  nibbling  efforts 
have  served  their  purpose.  During  the  year 
1921  a  major  attack  against  malaria  has  been 
opened  along  the  entire  front,  including  town, 
village,  and  the  open  country.  The  unit  of 
operations  is  the  county.  Malaria  control  is 
undertaken  as  a  part  of  the  permanent  county 
health  scheme;  is  supported  by  state,  county, 
and  local  funds;  and  is  under  the  direction  of 
the  county  health  officer. 

All  available  measures  are  employed,  each  re- 
ceiving emphasis  according  to  local  conditions. 
In  Alabama,  where  an  energetic  sanitary  engineer 
is  co-operating  with  the  health  officers  in  a  group 


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INTERNATIONAL    HEALTH    BOARD  II5 

of  five  counties,  mosquito  control  is  being  ex- 
tended to  rural  communities.  The  top  minnow 
— shown  by  Dr.  Howard  in  his  experiment  in 
Mississippi  to  be  effective  and  economical  in 
controlling  mosquito  breeding  about  farm  houses 
— is  the  principal  agent  here.  The  farmers  are 
maintaining  minnow  ponds  from  which  mosquito- 
breeding  waters  may  be  easily  stocked  with  fish. 
In  the  Mississippi  delta,  on  the  other  hand, 
where  mosquito  control  is  less  feasible,  anti- 
mosquito  measures  are  not  neglected  where  con- 
ditions favor,  but  greater  emphasis  is  being  placed 
on  sterilizing  quinine  treatment.  In  all  counties 
where  the  work  has  been  undertaken  the  people 
are  being  taught  to  screen  their  houses  as  a  pro- 
tection against  flies  and  mosquitoes.  The  stand- 
ard quinine  treatment  for  those  who  have 
malaria  is  provided  at  convenient  points  and  its 
use  is  being  stimulated  by  systematic  education. 
This  county-wide  effort  is  being  undertaken  not 
as  a  brief  intensive  drive,  but  as  a  slow,  steady 
campaign  to  be  continued  over  a  period  of  years. 

Field  Experiments  in  Malaria  Control 

A  limited  number  of  field  experiments  are  being 
continued.  As  a  result  of  Dr.  Bass's  work  in 
Bolivar  and  Sunflower  counties  in  Mississippi 
a  standard  quinine  treatment  for  malaria  in  this 
region  has  become  established  and  its  use  is  being 


Il6      THE  ROCKEFELLER  FOUNDATION 

gradually  extended  to  other  counties  and  states. 
At  Mound,  Louisiana,  tests  are  being  carried  out 
with  a  view  to  getting  additional  information  on 
the  screening  of  houses  as  a  factor  in  malaria  con- 
trol; the  effect  of  the  location  of  houses,  in  rela- 
tion to  mosquito-breeding  places,  on  the  incidence 
and  severity  of  malaria;  effect  of  killing  adult 
mosquitoes  in  homes;  control  of  mosquito  breed- 
ing by  top  minnows  and  wave  action,  in  connec- 
tion with  impounding  water  in  bayous  and  keep- 
ing down  the  marginal  vegetation  by  pasturage. 
An  experiment  has  been  undertaken  in  Nicaragua 
to  test  the  control  of  mosquitoes  in  a  small  town, 
under  tropical  conditions,  by  the  simple  and  rela- 
tively inexpensive  measures  that  have  been  suc- 
cessful in  the  Southern  States.  A  similar  test  is 
being  conducted  in  Porto  Rico  in  an  agricultural 
area. 

Ill 

Fighting  Tuberculosis  in  France 

The  commission  which  the  Board  sent  to 
France  in  1917  to  aid  in  organizing  a  national 
crusade  against  tuberculosis  is  well  within  sight 
of  the  end  of  its  task.  Responsibility  is  being 
rapidly  transferred  to  French  authorities.  When 
the  work  began  four  years  ago  the  French  govern- 
ment and  people  were  bearing  the  burdens  of  a 
devastating  war  and  were  carrying  the  additional 


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INTERNATIONAL    HEALTH    BOARD  IIQ 

weight  of  a  heavy  tuberculosis  rate  which,  as  in 
all  the  warring  countries,  was  supposed  to  be  on 
the  increase.  There  were  in  the  country  at  that 
time  but  twenty-two  tuberculosis  dispensaries, 
and  for  persons  needing  hospital  or  sanatorium 
care  not  more  than  8,000  beds. 

To  meet  the  situation  a  great  multiplicity  of 
agencies — French  and  American,  official  and  non- 
official,  military  and  civilian — pooled  their  in- 
terests in  a  spirit  of  team-play  that  made  possible 
a  coherent  program.  A  scheme  was  projected 
on  a  national  scale.  It  undertook  to  promote 
the  establishment  of  tuberculosis  dispensaries; 
to  develop  nursing  schools  for  the  training  of 
public  health  visitors;  to  provide  graduate  courses 
for  the  training  of  doctors  for  the  service;  to  es- 
tablish a  central  records  and  statistical  service; 
to  conduct  a  nation-wide  campaign  of  popular 
education;  and  in  the  end  to  stimulate  the  pro- 
vision of  hospital  beds  and  sanatoria  for  the  cases 
that  need  such  care. 

This  united  effort  has  met  with  enthusiastic 
response.  The  whole  of  France  has  been 
reached  through  the  press  and  by  literature  in  the 
schools.  Mobile  exhibits  with  teaching  personnel 
have  covered  systematically  fifty-four  depart- 
ments. In  sixty-four  departments  the  usual 
organization  has  been  set  up,  providing  for  the 
operation  of  dispensaries  and  the  maintenance  of 


120      THE  ROCKEFELLER  FOUNDATION 

hospital  beds.  The  national  government  is  grant- 
ing subventions  for  the  building  of  sanatoria. 
Eight  training  schools  for  public  health  visitors 
are  in  operation;  and  of  these,  five  seem  to  be  on 
a  permanent  basis.  Beginning  with  1922  all  but 
one  are  to  offer  a  two-year  course.  Diplomas  have 
been  given  to  about  250  women  who  have  com- 
pleted the  course  and  who  are  now  serving,  some 
of  them  as  departmental  supervisors,  the  others 
in  local  dispensaries.  The  graduate  course  in 
tuberculosis,  which  from  the  beginning  awakened 
unexpected  interest,  has  been  completed  by  264 
dispensary  physicians.  All  activities  undertaken 
in  1917 maybe  regarded  as  rooted  in  French  soil; 
they  are  being  supported  by  Government  and  the 
people.  The  commission  has  been  dissolved. 
Dr.  Linsly  R.  Williams  with  a  limited  American 
staff  represents  the  Board  in  completing  the 
transfer  of  responsibility.  Comradeship  in  this 
service  to  all  who  have  shared  it  has  been  an  in- 
spiring privilege. 

IV 

Using  the  Hookworm  in  Promoting  Public  Health 

Of  the  estimated  seventeen  hundred  million 
people  inhabiting  the  globe,  something  more  than 
nine  hundred  million  live  in  countries  where 
hookworm  infection  is  a  serious  menace  to  health 
and  working  efficiency.     With  increasing  pres- 


INTERNATIONAL    HEALTH    BOARD  121 

sure  for  the  development  of  tropical  and  sub- 
tropical lands  the  control  of  this  disease — as  of 
malaria  and  sleeping  sickness — becomes  a  matter 
of  serious  international  concern.  Hookworm 
disease  has  been  selected  by  the  Board  for  special 
consideration,  however,  not  primarily  because  of 
its  relative  importance  as  a  disabling  disease, 
great  as  that  is,  but  rather  because  it  lends  itself 
readily  to  purposes  of  demonstration  in  disease 
control.  It  serves  at  once  as  an  end  in  itself  and 
as  a  convenient  means  to  a  larger  end.  The 
work,  while  bringing  immediate  relief  to  hundreds 
of  thousands  of  suffering  people,  is  at  the  same 
time  serving  the  more  useful  purpose  of  creating 
a  popular  sentiment  in  support  of  permanent 
agencies  for  the  promotion  of  the  public  health. 
During  the  year  the  Board  contributed  toward 
demonstrations  in  hookworm  control  in  forty- 
three  states  and  countries  throughout  the  in- 
fected zone;  completed  infection  and  sanitary 
surveys  in  the  states  of  Alagoas  and  Espirito 
Santo,  Brazil,  in  New  Guinea,  in  the  British 
Solomon  Islands,  in  Tasmania,  and  in  Queens- 
land; and  began  surveys  which  are  still  in  prog- 
ress in  New  South  Wales,  in  Western  Australia, 
and  in  Northern  Territory,  Australia.  Arrange- 
ments were  entered  into  with  Government  for  a 
series  of  demonstrations  in  Mauritius  and  Hon- 
duras.    Re-infection   surveys  to  determine  re- 


122 


THE  ROCKEFELLER  FOUNDATION 


suits  of  previous  work  and  to  serve  as  a  stimulus 
to  further  effort  were  carried  out  on  a  county- 
wide  scale  in  forty-five  counties  in  the  Southern 

United  States  and  in  a 
number  of  smaller  areas 
in  Jamaica  and  Brazil. 

The  character  of  the 
work  and  the  policy 
underlying  its  adminis- 
tration are  well  illus- 
trated in 


The  First  Field  Demon- 
stration 

The  first  systematic 
effort  to  control  hook- 
worm disease  in  the 
United  States  was  under- 
taken in  1910  in  Rich- 
mond county,  Virginia. 
It  was  under  the  direc- 
tion of  the  Virginia  State 
Board  of  Health,  with 
the  Rockefeller  Sanitary 


Fig.  25. — The  hookworm  story 
of  Richmond  county,  Virginia. 
When  the  first  demonstration  in 
hookworm  control  in  the  United 
States  was  begun  in  this  county 
in  1910,  82  per  cent  of  the  school 
children  were  infected.  As  a  re- 
sult of  intensive  treatment  the 
infection  was  reduced  in  fifteen 
months  to  35  per  cent.  Local 
agencies  set  in  motion  in  1910 
have  kept  up  the  work  until 
now  hookworm  infection  in  that 
county  is  negligible 


Commission  supplying 
the  funds.  An  infection  survey  made  in  April  of 
that  year  showed  an  average  infection  of  82.6  per 
cent  among  the  school  children.  In  one  large  sec- 
tion of  the  county  the  infection  was  found  to  in- 


INTERNATIONAL  HEALTH  BOARD      1 23 

volve  practically  the  entire  population  and  to  be 
extremely  severe.  There  followed  an  intensive 
effort  to  examine  all  the  people;  to  treat  those 
who  were  found  infected;  and  by  house-to-house 
visits  to  give  them  a  definite  understanding  of 
the  importance  and  the  means  of  preventing  soil 
pollution.  Sanitary  leagues  were  organized  in 
local  communities.  Latrines  were  installed  at 
all  the  schools  and  by  persistent  effort  were 
gradually  brought  into  use  at  nearly  all  the 
homes. 

A  second  survey  made  in  the  summer  of  the 
following  year  showed  that  the  infection  among 
the  school  children  had  dropped  from  82.6  to 
35.2  per  cent.  Then  the  interesting  thing  hap- 
pened. Outside  aid  was  withdrawn;  the  county 
and  its  communities  were  left  to  their  own  de- 
vices. A  third  survey  made  ten  years  later — 
in  the  summer  of  1921 — showed  that  the  in- 
fection among  school  children  had  dropped 
to  2.2  per  cent.  The  first  intensive  demon- 
stration in  1910,  while  reducing  hookworm  in- 
fection from  82.6  to  35.2  per  cent,  set  in 
motion  permanent  local  forces  which  within 
ten  years  have  reduced  the  infection  rate  to 
the  negligible  fraction  of  2.2  per  cent  (see  Fig. 
25,  page  122). 

And  while  conquering  hookworm  these  same 
forces  are  conquering  typhoid  and  dysentery  as 


124      THE  ROCKEFELLER  FOUNDATION 

well.  The  recent  survey  referred  to  above 
showed  that  the  people  have  latrines  at  their 
homes  and  are  using  them.  Only  two  negro 
homes,  two  white  tenant  homes,  and  one  white 
home  owned  by  the  occupant,  were  found  with- 
out such  protection.  The  late  Dr.  Fisher,  who 
had  been  a  practicing  physician  here  for  more 
than  thirty-five  years,  stated  that  typhoid  and 
dysentery  used  to  bulk  large  in  his  practice.  He 
had  not  had  a  case  of  either  of  these  diseases  for 
more  than  five  years.  He  also  reported — and 
the  statement  is  abundantly  supported  by  the 
facts  as  observed  by  the  General  Director, 
who  visited  the  community  in  June,  1911,  and 
again  in  November,  1921 — that  the  economic 
and  social  changes  which  have  come  within 
this  time  are  quite  as  great  as  the  improve- 
ment in  health. 

Results  in  Eleven  States 

The  service  inaugurated  in  1910  in  Richmond 
county  was  extended  rapidly  to  the  more 
heavily  infected  counties  of  eleven  southern 
states.  Results  similar  in  character — though 
less  on  the  average  in  degree  of  control — have 
been  accomplished  throughout  this  infected 
region.  Resurveys  carried  out  on  a  county-wide 
scale,  and  based  on  the  examination  of  school 
children — as  were  the  original  infection  surveys 


INTERNATIONAL    HEALTH    BOARD 


125 


of  1911-1914 — have  been  completed  in  fifty-six 
counties;  more  than  29,000  children  have  been 
examined  in  these  recent  tests.  The  results  show, 
for  the  fifty-two  counties  for  which  compara- 
tive records  are  now  available,  a  decline  in  the 
average  in- 
fection rate 
from  57.8 
per  cent  in 
1911-1914 
to  27.7  per 
cent  in 
1920-1921. 
The  change 
wrought  in 
the  physi- 
cal appear- 
ance of  the 
people  is 
obvious 
even  to  the 
casual  ob- 
server. As 
in  Rich- 
mond county,  so  over  the  larger  region,  typhoid 
and  dysentery  also  are  being  brought  under  con- 
trol (see  Fig.  26). 

The  point  to  be  emphasized  is  that  although  the 
original  intensive  demonstrations  in  which  nearly 


Fig.  26. — Decline  in  incidence  of  dysentery  and 
typhoid  fever,  Troup  county,  Georgia,  1917-1921, 
inclusive.  The  prevention  of  soil  contamination, 
brought  about  through  the  work  of  the  county  health 
departments,  accomplishes  not  only  the  control  of 
hookworm  but  of  other  soil-borne  diseases  as  well 


126 


THE  ROCKEFELLER  FOUNDATION 


three  fourths  of  a  milUon  people  were  treated  in 
these  states  contributed  to  the  immediate  reduc- 
tion of  the  infection  both  in  degree  and  in  preva- 
lence, the  results  have  been  accomplished  in  the 
main  by  permanent  local  agencies  rooted  in  the 

soil.  These  forces  are 
continually  active,  are 
committed  to  the  task, 
and  may  be  depended 
upon  to  complete  it. 


11,543.316 — 


Jl,930,*«8- 


Board's  Work  Completed 

The  object  which  the 
Board  had  in  view  has 
been  accomplished.  Dur- 
ing the  year  the  ar- 
rangement by  which  the 
Rockefeller  Sanitary 
Commission  and  later  the 
International  Health 
Board  had  shared  with 
the  states  in  measures  for 
the  relief  and  control  of  hookworm  disease  was 
brought  to  a  satisfactory  close.  Heads  of  health 
departments  have  seen  develop  in  these  states,  in 
response  to  their  efforts,  a  strong  public  senti- 
ment in  support  of  sound  and  aggressive  public 
health  poHcy.  State  legislative  appropriations 
for  health  purposes  have  increased  more  than 


Fig.  27. — Appropriations  of 
legislatures  to  state  boards  of 
health  in  eleven  southern  states 
1910-1921.  Includes  funds  for 
anti-tuberculosis  work 


INTERNATIONAL  HEALTH  BOARD      1 27 

nine-fold  during  the  eleven  years  (see  Fig.  27, 
page  126).  County  health  departments  sup- 
ported in  the  main  by  county  funds  have  de- 
veloped and  are  developing  more  rapidly  than 
it  has  been  possible  to  provide  properly  trained 
men  (see  Fig.  65,  page  206). 

Termination  of  the  Board's  participation  in 
measures  directed  specifically  to  the  control  of 
hookworm  disease  does  not  disturb  working  rela- 
tions with  these  states.  It  makes  possible  rather 
a  transfer  of  funds  to  the  further  development  of 
the  more  general  county  health  program,  to  the 
fight  against  malaria,  and  to  the  training  of  per- 
sonnel for  the  technical  and  administrative  posi- 
tions which  are  being  created. 

Testing  Results  in  Brazil 

With  a  view  to  testing  the  effectiveness  of  field 
operations  in  Brazil  Dr.  W.  G.  Smillie,  Director 
of  the  Institute  of  Hygiene  at  Sao  Paulo,  made  a 
resurvey  during  the  year  in  two  communities 
within  the  Federal  area.  The  test  was  based  on 
worm  counts.  Though  the  usual  microscopic 
examination  of  stools  showed  but  slight  reduction 
in  the  percentage  of  persons  infected  in  either  of 
these  communities,  the  number  of  parasites  ex- 
pelled showed  a  striking  result.  In  one  of  the  two 
communities  where  latrine  construction  had  not 
been  thorough  the  group  that  had  been  treated 


128 


THE  ROCKEFELLER  FOUNDATION 


8  100 

I 

o 

OQ 

s 

Z 


A 

-Y  TREATED 

;D  3  YEARS 

)  BEFORE 

(52  Cases) 


Fig.  28.— Control  of  hook- 
worm disease  as  result  of  cam- 
paign measures  applied  in  1918 
in  Jacarepagua,  Brazil.  In  that 
year  the  infected  inhabitants 
harbored  on  an  average  approxi- 
mately 200  worms;  in  1921  they 
harbored  only  forty-two 


at  the  time  of  the  original 
demonstration  harbored 
on  the  average  forty-two 
parasites  per  person,  while 
a  group  that  had  escaped 


ap- 


-a    re- 


treatment  averaged 
proximately  200,- 
duction  of  79  per  cent. 
In  the  other  community 
where  latrine  construction 
had  been  more  thorough 
the  test  indicated  that  the 
original    campaign,    with 


Fig.  29. — Reduction  of  hook- 
worm disease  as  result  of  con- 
trol measures,  Governor's  Is- 
land, Brazil.  (In  this  graph 
and  in  Fig.  28  the  cases  repre- 
sented by  the  bar  "Previously 
Untreated"  are  few  in  number 
because  the  population  of  both 
places  is  largely  transient.  No 
considerable  number  of  persons 
could  be  found  in  1921  who  had 
lived  there  and  had  not  been 
treated  at  the  time  of  the  origi- 
nal campaigns  in  1917-1918) 


INTERNATIONAL    HEALTH    BOARD 


129 


the  continued  operation  of  local  forces,  had  within 
four  years'  time  reduced  by  95  per  cent  the  num- 
ber  of    hookworms    har- 
bored  (see  Figs.   28  and 
29,  page  128).^ 


FEMALES 


TYPICAL  UNTREATED  RURAL 
RESIDENTS  OF  BRAZIL 


\RURAL  RESIDENTS  OF 
OOVERNOR-S  ISLAND 


Transferring  Responsibility  to 
Brazilian  Government 

The  work  inaugurated 
in  1916  in  the  state  of 
Rio  and  rapidly  extended 
to  the  Federal  area  and 
eleven  states  is  being 
taken  over  by  govern- 
ment authorities  as  part 
of  a  permanent  scheme 
of  rural  sanitation.  For 
this  purpose  appropria- 
tions, state  and  federal, 
have  increased  from  312,- 
556  in  1917  to  22,072,500 
in  1921  (see  Fig.  31, 
page  130).  The  Board  is 
gradually  transferring  its  funds  from  demon- 
strations in  hookworm  control  to  the  develop- 
ment of  a  county  health  organization;  the 
introduction  of  a  public  health  nursing  service;  ^ 

^  For  details,  see  The  Results  of  Hookworm  Disease  Prophylaxis  in 
Brazil,  by  Wilson  G.  Smillie.  The  American  Journal  of  Hygiene,  January, 
1922,  V.  2,  No.  1,  pp.  91-94.     Same  reprinted. 

2  See  page  153. 


Fig.  30. — Effect  of  treatment 
and  the  installation  of  latrines 
on  severity  of  hookworm  infec- 
tion. Worms  harbored  by- 
typical  untreated  rural  resi- 
dents of  Brazil  compared  with 
those  harbored  in  1921  by  the 
rural  residents  of  Governor's 
Island,  who  were  treated  three 
years  previously 


130 


THE  ROCKEFELLER  FOUNDATION 


field  experiments  in  the  fight  against  malaria;  and 
the  development  of  a  school  of  pubUc  health.^ 
An  arrangement  has  been  entered  into — the  state, 
the  county,  and  the  Board  providing  the  funds — 
for   the  first   demonstration   of  county   health 

service    in    the    state   of 

Sao  Paulo. 

Progress  in  Permanent  Sani- 
tation in  tlie  West  Indies 

An  illuminating  field 
study  carried  out  in 
Trinidad  during  the  year 
by  Cort  and  Payne  ^ 
proved  to  be  a  striking 
demonstration  of  the  ef- 
fectiveness of  the  meas- 
ures that  are  being  carried 
out  on  a  large  scale  in 
Fig.  3L— Increase  in  funds    many  lauds,  and  partic- 

for   rural    sanitation   appropri- 
ated by  Federal  and  local  gov-      ularlv    of    the     SOUuduCSS 
ernments  in  Brazil,  1917-1921  i-  . 

of  government  policy  m 
building  up  sanitary  organizations  to  make  the 
results  permanent. 

Governments  are  becoming  increasingly  active 
in  Dutch  Guiana,  British  Guiana,  Trinidad, 
Porto  Rico,  and  Jamaica,  in  providing  funds,  in- 
creasing their  sanitary  staffs,  and  in  carrying  out 

^  See  page  144. 

*  Summarized  on  pages  175  to  180. 


INTERNATIONAL    HEALTH    BOARD 


131 


practical  operations  in  the  field.  For  the  year 
1921  Porto  Rico  appropriated  ?800,000  for 
public  health  purposes,  including  a  tuberculosis 
sanatorium;  set  aside  330,000  of  this — in  ad- 
dition to  the  necessary  overhead — for  the  fight 
against  hookworm  disease;  and  with  an  effi- 
cient field  staff 
under  central  di- 
rection established 
a  creditable  stand- 
ard of  soil  sanita- 
tion in  all  areas  of 
operation  well  in 
advance  of  the  mo- 
bile clinics.  The 
present  field  staff 
is  to  be  the  nucleus 
of  a  permanent 
system  of  inspec- 
tion. 


Fig.  32. — States  of  Brazil  that  have 
funds  available  for  a  program  of  rural 
sanitation.  Most  of  the  states  are  receiv- 
ing Federal  aid 


In  Trinidad  Government  has  committed  itself 
to  the  support  of  a  general  scheme  of  public 
health;  has  recently  appointed  one  medical  officer 
of  health  with  provision  for  a  second;  has  inaugu- 
rated a  comprehensive  plan  of  malaria  control;  is 
providing  about  335,000  a  year  for  the  mainte- 
nance of  its  sanitary  staff;  has  recently  added  to 
it  three  European  inspectors;  and  has  in  progress 
an  extensive  program  of  latrine  construction.     In 


132 


THE  ROCKEFELLER  FOUNDATION 


Dutch  Guiana,  where  only  recently  operations 
were  resumed  after  enforced  suspension  during 
the  war,  Government  is  giving  energetic  support; 

has  provided  a  staff  of 
sanitary  inspectors  for 
Lower  Surinam  and 
Lower  Para;  and  with 
the  hearty  co-operation  of 
the  estates  population  is 
effecting  a  thoroughgoing 
reform  in  these  regions. 

In  Jamaica  the  harass- 
ing— and  at  times  appar- 
ently hopeless — inertia 
that  early  effort  in  the 
island  had  to  face  has 
yielded  to  a  popular  in- 
terest that  is  becoming 
increasingly  general  and 
aggressive.  A  striking 
demonstration  in  one 
community  shows  a  fall 
in  infection  rate  from  55 
per  cent  in  1919  to  13  per 
cent  in  1920,  and  to  9  per 
cent  in  1921  (see  Fig. 
33).  Areas  of  operation  are  now  being  sanitated 
in  advance  of  treatment.  A  conference  of  pa- 
rochial boards  in  December  adopted  a  resolution 


Fig.  33. — Reduction  of  hook- 
worm infection  rate  on  estates 
in  the  Vere  area,  Jamaica. 
First  survey,  November,  1919; 
second  survey,  May  to  October, 
1920;  third  survey,  August, 
1921.  The  estate  management 
is  continuing  systematic  treat- 
ment and  also  installing  latrines 
in  an  effort  to  stamp  out  the 
infection 


INTERNATIONAL  HEALTH  BOARD      1 33 

approving  the  appointment  of  a  superintending 
medical  officer  for  the  colony  and  a  whole-time 
health  officer  in  each  of  the  parishes,  with  ade- 
quate field  staff  to  establish  a  system  of  in- 
spection. Government  is  preparing  to  expend 
2100,000  on  sanitation  during  the  year  1922. 

Developing   National    Health   Organization    in   Central 
America 

In  Central  American  countries — and  partic- 
ularly in  Costa  Rica,  Nicaragua,  and  Salvador — 
measures  undertaken  in  1914  and  1915  against 
hookworm  disease  have  passed  successfully 
through  the  primary  stage  of  field  demonstra- 
tion. Responsibility  is  being  gradually  trans- 
ferred to  government  authorities,  and  control  of 
the  one  disease  is  being  merged  into  more  general 
schemes  of  public  health.  In  Panama,  where 
development  of  local  initiative  has  been  stifled 
by  the  paternalistic  policy  of  the  Canal  Zone, 
the  formation  of  a  responsible  department  of 
health  is  now  being  considered.  Government 
is  slowly  developing  a  sanitary  staff  and  is  pro- 
viding 212,500  a  year  for  the  work  of  the 
department  of  uncinariasis,  or  hookworm  con- 
trol. 

In  Costa  Rica  the  service  was  formally  taken 
over  on  May  28,  1921,  as  a  division  under  the 
newly  established  national  department  of  health, 


134      THE  ROCKEFELLER  FOUNDATION 

and  the  Board's  representative  was  withdrawn. 
A  limited  contribution  toward  its  maintenance  is 
being  continued  through  1922,  and  provision  has 
been  made  by  means  of  fellowships  for  the  training 
of  additional  men  for  the  posts  that  are  being  cre- 
ated. In  Nicaragua  a  commission  appointed  for 
the  purpose  by  the  President  has  drafted  a  sani- 
tary code  for  the  country  and  a  law  establishing 
a  national  department  of  health  to  carry  it  out. 
The  Board  is  lending  the  services  of  a  trained 
scientist  to  organize  and  direct  a  modest  diagnos- 
tic laboratory,  and  is  providing  for  the  training  of 
a  limited  number  of  native  doctors  for  the  new 
government  service.  The  division  of  uncinaria- 
sis is  to  be  the  nucleus  around  which  the  new 
department  is  to  be  formed. 

Salvador  has  had  a  national  health  organ- 
ization for  many  years.  During  the  year  Gov- 
ernment has  reconstituted  it  in  the  interest  of 
more  aggressive  action  in  the  field.  The  new 
scheme  correlates  the  various  government  medi- 
cal services  under  central  control;  provides  new 
and  adequate  quarters;  reinforces  the  staff"; 
creates  a  public  health  laboratory;  takes  over  as 
one  of  its  divisions  uncinariasis  control;  and 
provides  an  annual  budget  of  170,000  colones, 
in  addition  to  supplying  26,000  colones  for  the 
relief  and  control  of  hookworm  disease  and  half 
the  funds  needed  for  the  fight  against  yellow 


INTERNATIONAL    HEALTH    BOARD  I3S 

fever.     The  Board  undertakes  to  aid  In  the  train- 
ing of  additional  men. 

Promoting  Public  Health  in  the  Far  East 

In  the  Far  East  the  Board  is  sharing  in  a  wide 
range  of  activities  representing  pretty  well  all 
stages  of  public  health  development.  In  Borneo 
the  first  demonstration  in  the  control  of  hookworm 
opened  with  Government  supplying  a  large  part  of 
the  funds  and  the  native  population  giving  will- 
ing co-operation.  In  Fiji,  where  operations  had 
been  suspended  during  the  war,  adequate  latrine 
accommodations  were  installed  over  a  wide  area 
preparatory  to  reopening  the  clinics  early  in 
1922.  Government  is  to  assume  entire  re- 
sponsibility at  the  end  of  three  years.  The  in- 
fection survey  of  Mauritius — completed  in  1920 
— led  to  an  arrangement  by  which  the  Board  is  to 
share  on  a  sliding  scale  for  a  period  of  three  years 
in  a  series  of  demonstrations  in  control  measures, 
leaving  Government  at  the  end  of  that  time  in 
full  charge.  In  the  meantime  aid  Is  being  given 
in  the  training  of  local  men.  In  Madras  Presi- 
dency, India,  where  surveys  made  between  1915 
and  1920  showed  a  rate  of  nearly  100  per  cent 
among  the  laboring  population,  a  scheme  of 
practical  operations  for  the  Presidency  has  been 
approved,  Government  supplying  all  necessary 
funds  save  the  salary  and  traveling  expenses  of 


136      THE  ROCKEFELLER  FOUNDATION 

the  director.  In  the  face  of  a  sharp  economic 
crisis  in  Ceylon  operations  are  continuing,  al- 
though on  a  diminished  scale.  A  proposed  re- 
vision of  the  sanitary  law  is  indication  of  an 
interest  in  a  more  aggressive  public  health  policy 
for  the  colony. 

In  Siam  the  National  Red  Cross  is  taking  a 
leading  part  in  the  fight  against  hookworm  dis- 
ease. Government  has  enlisted  the  army,  the 
navy,  the  gendarnierie,  and  the  local  chiefs.  For 
more  than  a  year  the  dispensaries  have  been 
treating  on  the  average  more  than  1,000  persons 
per  week;  and  an  active  propaganda  has  created 
a  demand  that  the  service  be  made  national  in 
scope.  Plans  are  now  under  consideration  for 
putting  the  medical  school  at  Bangkok  on  a 
modern  basis  as  a  necessary  first  step  toward  the 
training  of  Siamese  for  public  health  work. 

The  five-year  scheme  entered  into  with  Aus- 
tralia in  1918  is  now  being  operated  under  the 
new  Commonwealth  Ministry  of  Health  which 
was  created  last  year.  The  services  of  Dr.  W.  A. 
Sawyer,  the  Board's  representative,  are  being 
lent  to  the  Ministry  for  a  limited  time;  Dr. 
A.  J.  Lanza  has  gone  out  to  organize  a  divi- 
sion of  industrial  hygiene;  Mr.  F.  F.  Longley 
is  to  set  up  a  division  of  sanitary  engineering; 
and  Dr.  F.  F.  Russell,  of  the  Board's  staff,  is  to 
make  a  brief  visit  toward  the  end  of  1922  to  aid 


\/^Mmwmf^' ifms^ 

s 

<*?■#¥ 

^m 

kl': 

[ii 

^^cr^^wCW 

iJWjff. 

1^ 

Fig.  34. — Carrying  the  gospel  of  sanitation  to  the  natives 
of  Solomon  Islands.  Plantation  group  assembled  for  lec- 
ture on  hookworm  disease  at  Rendova 


Fig.  35. — Group  of  Moors  assembled  at  village  dispen- 
sary to  be  treated  for  hookworm  disease.  After  witnessing 
the  results  of  five  years'  demonstration  work  among  the 
Tamil  estate  population,  large  numbers  of  Moors  are  now 
voluntarily  applying  for  treatment 


4 

^  A^ii^^^^^^.  .^^^is 

_j|^Hr^\iWWH|^raSH^i '"--S^^ 

^ 

^.^''5^'Wiii 

^ 

^ip^-'^^W 

lE; 

Fig.  36.  Three  phases  of  field  operations  against  hook- 
worm disease  in  Papua.  Upper  left:  medical  officer  exam- 
ining fecal  specimen  for  hookworm  eggs,  Yule  Island; 
upper  right:  native  assistant  in  uniform  of  hookworm  cam- 
paign staff;  below:  group  of  natives  assembled  to  hear 
lecture,  Sabuia 


INTERN ATIONA.L    HEALTH    BOARD  1 39 

in  the  planning  of  a  system  of  public  health 
laboratories.  In  the  meantime  young  Australi- 
ans are  being  trained  for  these  positions. 

Just  at  the  close  of  the  year  comes  a  call  from 
the  Philippines.  In  response  to  Government  re- 
quest the  Board  has  undertaken  to  lend  the 
services  of  Dr.  Heiser,  Director  of  its  work  for  the 
East,  for  a  period  of  three  months;  to  provide  a 
competent  woman  to  aid  in  developing  a  public 
health  nursing  service  for  the  Islands;  to  provide, 
for  two  years,  a  trained  director  for  the  public 
health  laboratory  in  connection  with  the  Bureau 
of  Science;  to  detail  a  speciaHst  to  carry  out  a 
malaria  survey;  and  to  provide  by  means  of  fel- 
lowships for  training  a  limited  number  of  Fili- 
pinos in  public  health. 

On  Their  Own  Initiative 

The  year  has  brought  reports  of  government 
and  voluntary  effort  against  hookworm  disease  in 
which  the  Board  has  not  shared.  Reference  has 
been  made  in  previous  reports  to  the  admirable 
work  done  in  Assam  under  the  direction  of 
Colonel  Sir  Clayton  Lane  and  to  the  eminent 
achievements  of  Schiiffner  and  his  colleagues  in 
Sumatra.  Paraguay  took  up  the  task  two  or 
three  years  ago;  and  now  the  Egyptian  govern- 
ment is  resuming  operations  which  had  been  sus- 
pended during  the  war.     Dr.  Gann,  Principal 


140      THE  ROCKEFELLER  FOUNDATION 

Medical  Officer  of  British  Honduras,  has.  com- 
pleted a  campaign  extending  over  a  period  of 
three  years  and  covering  systematically  the  in- 
fected areas  of  the  country.  The  infected  have 
been  treated;  latrines  have  been  provided,  and 
the  people  have  been  taught  to  use  them.  It  is 
now  proposed  to  make  the  results  permanent 
by  a  system  of  sanitary  inspection.  The  report 
from  British  Honduras  forces  upon  the  reader 
the  thought  that  if  government  medical  officers 
everywhere  had  the  public  health  point  of  view 
and  something  of  Dr.  Gann's  aggressive  energy, 
many  of  the  cases  of  illness  that  are  being  treated 
in  expensive  hospitals  would  not  occur. 

Greater  Speed  and  Economy  in  Field  Operations 

Results  of  the  studies  by  Darling  and  Smillie  in 
the  administration  of  treatment  for  hookworm 
disease,  and  the  more  recent  resurveys  based  on 
worm  counts  made  by  Smillie  in  Brazil,  suggest 
important  modifications  in  field  procedures. 

The  findings  of  Smillie  in  Brazil  and  of  Cort 
and  Payne  in  Trinidad,  for  example,  put  be- 
yond further  question  the  value  of  mass  treat- 
ment even  when  considered  merely  as  a  pro- 
phylactic measure.  It  is  now  known  that  by 
administering  two  standard  doses  of  oil  of 
chenopodium  as  a  routine  measure  about  95  per 
cent  of  the  para3ite§  harbored  by  the  people  of  a 


INTERNATIONAL    HEALTH    BOARD  I4I 

community  may  be  expelled.  To  attempt  to  get 
rid  of  the  remaining  5  per  cent  by  following  each 
case  to  a  complete  cure  would  double  the  cost. 
By  leaving  this  small  fraction  of  infection — 
which  is  not  of  great  clinical  importance — to  be 
taken  care  of  by  sanitation,  it  has  been  found 
possible  greatly  to  reduce  the  cost  and  increase 
the  speed  of  field  operations.  A  preliminary 
comparative  test  in  Brazil  indicates  a  saving  by 
this  modification  of  about  50  per  cent  in  per 
capita  cost.i 

Field  Studies  in  Hookworm  Control 

Reference  has  been  made  above  to  two  or  three 
studies  that  have  been  extremely  fruitful  in 
practical  results.  In  this  field  1921  has  been  the 
most  productive  year  in  the  history  of  the  Board. 
Colonel  Sir  Clayton  Lane,  with  a  small  subven- 
tion, has  been  seeking  to  improve  the  technique 
of  stool  examination.  Beta-naphthol  has  been 
given  a  further  test  as  an  anthelmintic  on  an  ex- 
tensive scale  and  under  field  conditions  by 
Mhaskar  and  Kendrick  in  India.  Ascaridol  has 
been  administered  on  a  relatively  small  scale  and 
with  good  results  by  Smillie  in  Brazil,  Mhaskar  ^ 

^  For  details  of  working  plan  suggested  by  Dr.  Smillie  see  pages  180 
and  181  of  this  report;  and  Dr.  Smillie's  article  "The  Result  of  Hook- 
worm Disease  Prophylaxis  in  Brazil";  published  in  Th(  Jm^rkan 
Journal  of  Hygiene,  January,  1922  (v.  2,  No.  1,  p.  77-95). 

*  Working  under  the  Indian  Research  Fund. 

JO 


142      THE  ROCKEFELLER  FOUNDATION 

in  India,  and  Molloy  in  Nicaragua.  The  ad- 
ministration of  chenopodium  without  preliminary 
purge  has  been  further  tested  under  field  condi- 
tions in  Australia,  Costa  Rica,  Panama,  Salvador, 
and  Colombia.  The  practice  is  becoming  general. 
Dr.  Washburn  in  Jamaica  reports  continued  satis- 
factory results  from  the  use  of  compound  jalap 
powder.  The  most  interesting  contribution  in 
the  field  of  treatment  is  by  Dr.  M.  C.  Hall  i  of  the 
Department  of  Agriculture,  Washington,  D.  C, 
in  administering  carbon  tetrachloride  to  dogs  with 
100  per  cent  efficiency  for  hookworms.  The  Willis 
salt-flotation  method  of  stool  examination  has 
been  tested  on  an  extensive  scale  in  the  field  and 
found  to  be  efficient,  rapid,  and  economical. 
Molloy  of  Nicaragua  contributed  an  important 
improvement.  Smillie  finds  that  counting  eggs 
on  the  slide  as  a  means  of  estimating  severity  of 
infection,  while  serving  as  a  rough  indication 
when  large  groups  are  considered,  is  of  small  value 
in  individual  cases.  Cort  developed  an  improved 
apparatus  for  the  recovery  of  hookworm  larvae 
from  the  soil,  and  Smillie  made  an  important 
contribution  to  the  technique  of  differentiating 
hookworm  and  Strongyloides  larvae.  Dr.  Cald- 
well, in  Panama,  completed  a  study  of  the  relation 
of  the  action  of  sea-water  on  hookworm  eggs  and 


1  No  connection  with  Board's  staff. 


INTERNATIONAL    HEALTH    BOARD  1 43 

larvae  to  the  extremely  light  infection  among  the 
San  Bias  Indians  living  by  the  sea. 

A  small  subvention  by  the  Board  made  it  pos- 
sible for  Dr.  Cort,  helminthologist  in  the  Hopkins 
School  of  Hygiene,  to  go  with  a  competent  staff 
to  Trinidad,  British  West  Indies,  for  a  series  of 
field  investigations  covering  a  period  of  about 
four  months.  It  proved  to  be  an  extremely 
fruitful  expedition.  The  results,  throwing  much- 
needed  light  on  practical  control  operations,  are 
being  published  in  the  form  of  ten  papers  ap- 
pearing serially  in  the  American  Journal  of 
Hygiene.  1 

V 

Developing  Schools  of  Hygiene 

In  the  autumn  of  1913,  soon  after  the  begin- 
ning of  operations  on  an  international  scale,  the 
Board  faced  the  fact  that  in  order  to  carry  out 
the  activities  it  had  undertaken  it  must  have  a 
staff  of  trained  hygienists;  and  that  the  countries 
in  which  it  was  proposed  to  encourage  public 
health  development  must  also  have  such  men. 
The  men  even  for  the  Board's  own  staff  were  not 
then  available.  Institutions  for  their  proper 
training — that  is,  institutions  covering  broadly 
the  whole  field  of  hygiene,  and  equipped  to  culti- 

^  For  a  more  detailed  summary  of  the  field  studies  referred  to  In  this 
section,  see  appendix,  pages  175  to  186. 


144      THE  ROCKEFELLER  FOUNDATION 

vate  it  as  a  science  and  to  train  men  in  its  appli- 
cation as  an  art — had  to  be  developed.  The 
outcome  was  a  direct  contribution  to  the  Johns 
Hopkins  University  to  establish  the  Hopkins 
School  of  Hygiene  and  Public  Health.  The 
school,  now  in  its  fourth  year,  enrolled  during  the 
year  1920-1921,  122  students. 

Since  1917  the  Board  has  been  contributing 
toward  the  development  on  a  very  modest  scale 
of  an  institute  of  hygiene  in  connection  with  the 
medical  school  at  Sao  Paulo,  Brazil.  This  in- 
stitute gives  an  undergraduate  course  in  hygiene 
to  the  students  in  the  medical  school;  conducts 
short  training  courses  for  public  health  officers; 
carries  out  epidemiological  field  studies  for  the 
state;  and  has  done  an  extremely  creditable 
amount  of  productive  scientific  work.  During 
the  year  the  Board  pledged  about  27,000,000 
crowns  toward  the  establishment  of  an  institute 
of  hygiene  at  Prague.  This  institute,  under  the 
Ministry  of  Health  and  in  close  relation  to  the 
University  Medical  School,  is  to  combine  a  cen- 
tral public  health  laboratory  for  Czechoslovakia 
with  a  school  of  instruction  for  public  health 
workers.  As  a  result  of  conferences  between  the 
officers  of  the  Board  and  the  authorities  of 
Harvard  University  and  its  medical  school  during 
the  early  months  of  the  year,  plans  were  matured 
and  approved  by  which  the  Rockefeller  Founda- 


INTERNATIONAL    HEALTH    BOARD  1 45 

tion  agreed  to  contribute  the  sum  of  32, 160,000 
toward  the  further  development  of  the  Harvard 
School  of  Public  Health.  The  resources  now 
available  are  regarded  as  quite  adequate  for  its 
immediate  needs. 

Fellowships  in  Hygiene  and  Public  Health 

In  accordance  with  the  policy  illustrated  in 
the  foregoing  section  the  Board  contemplates 
contributing  from  time  to  time,  as  conditions 
may  favor,  toward  the  development  of  a  limited 
number  of  schools  of  hygiene  at  strategic  points 
throughout  the  world.  As  these  institutions 
develop  they  will  necessarily  serve  to  stimulate 
and  reinforce  each  other  by  interchange  of  ex- 
perience, facilities,  and  men.  The  migration  of 
students  in  the  field  of  public  health  will  then  be 
feasible  on  a  much  more  satisfactory  scale  than  is 
possible  under  present  conditions.  In  the  mean- 
time, however,  the  Board  is  taking  advantage  of 
the  facilities  now  offered  in  England,  the  United 
States,  and,  by  recent  arrangement,  in  Canada, 
for  the  training  of  students  from  their  own  and 
other  lands ;  and  has  provided  by  means  of  fellow- 
ships for  a  limited  number  of  students  to  pursue 
courses  in  these  countries.  Fellowships  have 
been  granted  to  students  who  have  been  care- 
fully selected  with  reference  to  their  fitness  for 
important  posts  as  scientists,  teachers,  or  practi- 


146      THE  ROCKEFELLER  FOUNDATION 

cal  administrators  in  the  public  health  service, 
to  which  in  most  cases  they  have  had  definite 
assurance  of  appointment  on  completion  of  their 
courses.  These  fellowships  are  regarded  as  an 
investment  in  leadership.  For  the  year  1921 
fellowships  were  provided  for  fifty-four  men  and 
women  from  thirteen  countries,  as  follows: 

Brazil 5  Czechoslovakia .  19  Nicaragua ....  2 

Canada 2  France 4     Poland 3 

Ceylon 1  Guatemala 1     Salvador 2 

Colombia 1  Mexico 1  United  States .  11 

Costa  Rica ....  2 

Extension  Courses  in  Public  Health 

The  well-established  schools  of  hygiene  will 
give  short  courses  for  health  officers.  Under 
most  favorable  conditions,  however,  only  a  very 
limited  number  can  be  expected  to  attend  these 
institutions.  Each  state  will  find  it  necessary  to 
provide  practical  courses  for  the  better  training 
of  its  own  workers.  Modest  beginnings  in  this 
direction  are  being  made  in  the  form  of  training 
centers  of  limited  scope,  correspondence  courses, 
and  institutes.  During  the  year  the  Board  has 
contributed  toward  institutes  for  health  officers 
in  Georgia,  Ohio,  Michigan,  and  Alabama ;  toward 
three  institutes  for  public  health  nurses  in  New 
York  state;  and  toward  the  organization  of  a 
correspondence  course  to  be  conducted  by  the 
Ohio  department  of  health  for  full-time  county 
health  officers  in  that  state. 


Fig.  37. — Counting  hookworms  expelled  by  treated 
patients.  Field  research  conducted  under  the  auspices  of 
the  Department  of  Hygiene  of  the  Sao  Paulo  Medical 
School 


Fig.  38. — Group  assembled  at  typhoid  exhibit  at  Prague. 
One  of  the  earliest  activities  of  the  newly  organized  Min- 
istry of  Health  of  Czechoslovakia,  with  which  the  Inter- 
national Health  Board  is  co-operating,  was  an  educational 
campaign  against  this  disease 


INTERNATIONAL    HEALTH    BOARD  1 49 

VI 

Promoting  County  Health  Work 

For  reasons  which  are  well  understood  public 
health  effort  has  been  centered  mainly  on  the 
larger  towns  and  cities.  Health  protection  for 
the  people  living  in  country  districts  has  been 
neglected.  The  tide  is  turning.  The  develop- 
ment of  county  health  organization — which  is 
now  going  forward  with  considerable  momentum 
in  the  United  States — is  providing  a  service  for 
the  smaller  towns  and  rural  communities. 

In  the  Southern  States  county  health  adminis- 
tration developed  naturally  and  inevitably  from 
the  effort  to  control  hookworm  disease.  This 
is  a  rural  disease;  its  control  is  a  problem  in  rural 
sanitation;  a  serious  effort  to  handle  this  one 
problem  in  rural  sanitation  called  into  being 
county  organization.  County  organization  once 
established,  control  of  hookworm  disease  became 
merely  an  item  in  a  general  health  program  under 
state  and  county  administration.  The  demon- 
stration thus  given  of  the  value  of  the  county  as  a 
unit  in  the  state  scheme  stimulated  a  movement 
which  is  becoming  general.  At  the  close  of  the 
year  county  programs  on  a  full-time  basis  were  in 
operation  in  about  192  counties  in  the  United 
States  (see  map,  page  148). 


150      THE  ROCKEFELLER  FOUNDATION 

The  Board  and  the  United  States  Public 
Health  Service  are  aiding  this  movement  by 
contributing  toward  a  limited  number  of  demon- 
strations. The  average  county  health  budget  is 
about  310,000,  and  is  provided  from  state  and 
county  funds.  When  the  Board  shares  in  a 
demonstration,  it  contributes  toward  a  central 
budget  or  from  ?1,000  to  $2,S00  toward  the 
county  budget.  During  the  year  1921  aid  was 
thus  given  in  sixteen  states:  Alabama,  Florida, 
Georgia,  Kansas,  Kentucky,  Louisiana,  Mary- 
land, Mississippi,  Missouri,  New  Mexico,  North 
Carolina,  South  Carolina,  Tennessee,  Texas, 
Virginia,  West  Virginia.  A  similar  demonstra- 
tion is  being  carried  out  in  Czechoslovakia  and 
in  the  state  of  Sao  Paulo,  Brazil. 

Experiment  in  County  Healtli  Administration 

The  county  program,  which  is  essentially  a 
scheme  of  rural  public  health  work,  is,  for  the 
United  States,  a  new  undertaking.  It  invites 
critical  study  and  experiment.  A  joint  arrange- 
ment has  been  entered  into  by  the  Hopkins 
School  of  Hygiene,  the  Maryland  State  Depart- 
ment of  Health,  the  United  States  Public  Health 
Service,  and  the  International  Health  Board  by 
which  such  an  attempt  is  to  be  made.  The 
arrangement  provides  for  a  full-time  service  in  a 
county  easily  accessible  to  Baltimore  and  under 


liSrtERNAtlONAL    itEALtlt    BOARD  iSt 

the  immediate  direction  of  a  county  health  officer 
reporting  to  the  head  of  the  state  service. 
Washington  county  has  been  selected  for  the 
purpose  and  is  to  contribute  to  the  budget. 
The  county  is  expected  to  serve  as  a  field  labora- 
tory for  the  school,  and  to  provide  opportunity 
for  investigation  and  for  possible  contribution  to 
the  development  of  a  sound  plan  of  health  activi- 
ties for  rural  communities.  In  so  far  as  the 
undertaking  succeeds  it  will  serve  as  a  demonstra- 
tion and  as  a  training  base  for  students. 

VII 

Making  Public  Health  Laboratories  More 
Serviceable 

A  laboratory  service  —  like  vital  statistics 
— is  fundamental  to  intelligent  public  health 
administration.  The  trained  health  officer,  how- 
ever, understands  that  the  provision  of  buildings, 
equipment,  and  scientifically  trained  men  does 
not  of  itself  provide  the  service  he  needs.  Ag- 
gressive administration  is  equally  necessary  to 
make  these  facilities  available  to  the  people  they 
are  supposed  to  serve  and  to  educate  the  doctors 
and  people  to  use  them.  Under  Dr.  F.  F.  Rus- 
sell, Director  of  Public  Health  Laboratory  Serv- 
ice the  Board  has  shared  during  the  year  in  an 
increasing  number  of  projects  designed  to  pro- 
mote this  end. 


152      THE  ROCKEFELLER  FOUNDATION 

Dr.  Russell,  while  in  Europe  in  connection 
with  plans  for  the  Institute  of  Hygiene  at 
Prague,  made  brief  visits  for  his  own  information 
to  the  public  health  laboratories  at  the  three 
universities  of  Austria  and  some  of  the  principal 
institutes  of  hygiene  in  France — at  Nancy,  Lyons, 
Montpellier,  and  Paris.  These  laboratories  are 
doing  a  high  order  of  technical  work  and  are 
capable  of  doing  a  greater  amount  of  it  than  is 
being  required  of  them  by  the  physicians  of  the 
regions  they  serve.  Assistance  was  given  in 
Alabama  in  adapting  the  state  service  to  the 
larger  opportunities  opened  up  by  a  new  and 
adequate  laboratory  building.  Arrangement  was 
made  for  the  heads  of  the  laboratory  divisions 
in  Alabama  and  Mississippi  to  visit  the  labora- 
tories in  other  states  and  to  observe  the  work  of 
institutions  where  sera  and  vaccines  are  produced 
on  a  large  scale.  The  state  laboratories  in 
Tennessee  and  West  Virginia  were  visited  for 
consultation  regarding  possible  future  develop- 
ments. During  the  summer  months  Dr.  Russell 
visited  Panama,  Central  America,  and  Mexico. 
In  Nicaragua  arrangements  were  made  for  a 
diagnostic  laboratory  as  part  of  the  newly  cre- 
ated national  health  service.  In  Salvador  a 
national  laboratory  has  been  established  un- 
der the  department  of  health  and  is  being 
organized    by  Dr.    Segovia,   who   had   been   in 


INTERNATIONAL    HEALTH    BOARD  1 53 

training  for  this  purpose  on  a  fellowship  granted 
by  the  Board.  In  Guatemala  a  first  step  in  the 
direction  of  a  diagnostic  laboratory  has  been 
made  by  adding  to  the  equipment  and  staff  of  the 
central  laboratory  used  in  the  hookworm  work. 
In  Mexico  Government  has  plans  for  a  national 
institute  of  hygiene.  Here  the  Board  has  served 
as  agent  for  Government  in  finding  a  suitable 
American  to  direct  the  enterprise  for  a  limited 
period. 

VIII 

Establishing  a  Public  Health  Nursing  Service  in 

Brazil 

During  the  latter  part  of  1920  the  federal 
health  service  of  Brazil  became  a  national  de- 
partment of  health  with  greatly  enlarged  powers 
and  resources.  The  new  department,  with 
Dr.  Carlos  Chagas  as  its  distinguished  head, 
has  undertaken  among  other  things  a  nation- 
wide program  in  rural  sanitation  to  be  carried 
out  by  joint  arrangement  with  the  states;  and  for 
the  Federal  District  is  setting  up  new  divisions 
for  child  welfare,  venereal  disease  control,  and  a 
crusade  against  tuberculosis.  These  activities 
have  made  acute  the  need  of  trained  public  health 
nurses.  To  meet  the  situation  Government  is 
establishing  a  training  school  in  Rio  de  Janeiro. 
The  Board  has  undertaken  to  assist  in  securing  a 


154      THE  ROCKEFELLER  FOUNDATION 

competent  corps  of  American  nurses  to  operate 
the  field  dispensaries  and  the  training  school  for 
a  period  of  three  years.  In  the  meantime  a 
selected  group  of  Brazilian  women  are  to  be 
trained  with  a  view  to  taking  over  the  re- 
sponsibility. A  limited  number  of  dispensaries 
are  in  operation  and  plans  have  been  completed 
for  opening  the  training  school  early  in  the  com- 
ing year.  Arrangements  have  been  made  for 
recruiting  the  student  nurses  from  the  best 
graduates  of  the  normal  schools. 

IX 

Laying  Foundations  in  Czechoslovakia 

The  Ministry  of  Health  in  Czechoslovakia, 
confronted  with  the  task  of  creating  a  new  serv- 
ice for  the  country,  is  showing  great  wisdom  in 
undertaking  the  training  of  a  staff  of  selected 
young  men  to  develop  and  administer  it.  In  ac- 
cordance with  plans  matured  in  Prague  in  Febru- 
ary, 1920,  and  approved  by  the  International 
Health  Board  the  following  May,  provision  was 
made  for  a  commission  representing  the  Ministry 
to  study  public  health  administration  in  England 
and  the  United  States.  After  the  return  of  the 
commission  early  in  the  year  1921  the  Ministry 
set  up  a  committee  to  undertake  a  critical  revi- 
sion of  its  own  plans  and  procedures.     In  the 


INTERNATIONAL  HEALTH  BOARD      1 55 

general  scheme  which  is  being  put  into  operation 
first  consideration  is  being  given  to  a  few  funda- 
mentals: (1)  a  reporting  and  statistical  service 
that  shall  provide  the  information  which  the 
Ministry  and  local  health  officers  need  for  their 
daily  guidance;  (2)  a  public  health  laboratory 
service  that  shall  make  its  facilities  available  to 
all  the  people  of  the  country;  (3)  eff'ective  control 
of  the  ordinary  communicable  diseases;  (4)  pro- 
vision of  wholesome  water  supplies;  (5)  protec- 
tion against  contaminated  milk;  and  (6)  an  in- 
stitution for  the  adequate  training  of  personnel. 
The  Board  at  its  meeting  in  May  appropriated 
approximately  27,000,000  crowns  toward  the 
buildings  and  equipment  of  an  institute  of 
public  health  at  Prague;  and  provided  by  means 
of  fellowships  for  the  training  of  twenty-two 
young  Czechoslovaks  for  staff  positions  in  this 
institute  and  for  the  administrative  services  out- 
lined above. 

Publications 

During  the  year  1921  the  following  reports 
and  publications  were  issued  by  the  International 
Health  Board : 

Annual  Report  for  the  Year  1920. 

Infant  Mortality  In  New  York  City.     By  Ernst  Christopher  Meyer, 
Ph.D. 

Staff  members  and  others  directly  associated 
with  projects  in  which  the  Board  participated 


156  THE    ROCKEFELLER  FOUNDATION 

made  the  following  contributions  to  medical  and 
public  health  literature,  most  of  them  in  the 
form  of  articles  published  in  medical  journals 
that  are  widely  circulated  among  persons  inter- 
ested in  medical  and  public  health  topics: 

Bass,  C.  C. 

Diagnosis  of  the  commoner  intestinal  parasitic  infections.  South- 
ern Medical  Journal,  Nov.,  1921,  v.  14,  p.  863-865. 

Standard  treatment  for  malaria.  Public  Health  Reports,  July  1, 
1921,  V.  36,  p.  1502-1504. 

The  standard  treatment  for  malaria — a  discussion  of  some  of  its 
advantages.    Southern  Medical  Journal,  Apr.,  1921,  v.  14,  p.  280-288. 

Connor,  M.  E. 

Fish  as  mosquito  destroyers;  an  account  of  the  part  they  played 
in  the  control  of  yellow  fever  at  Guayaquil,  Ecuador.  Natural 
History,  1921,  v.  21,  p.  279-281.     Same  reprinted. 

CORT,  W.  W. 

Investigations  on  the  control  of  hookworm  disease;  general  intro- 
duction. American  Journal  of  Hygiene,  Sept.-Nov.,  1921,  v.  1,  p. 
557-568. 

CoRT,  W.  W.,  D.  L.  Augustine,  and  G.  C.  Payne 

Investigation  on  the  activities  of  infective  hookworm  larvae  in 
the  soil;  preliminary  report.  Journal  of  the  American  Medical 
Association,  Dec.  24,  1921,  v.  77,  p.  2035-2036. 

Darling,  S.  T. 

The  tertian  characters  of  quotidian  aestivo-autumnal  fever. 
American  Journal  of  Tropical  Medicine,  Nov.,  1921,  v.  1,  p.  397-408. 

Darling,  S.  T.  and  W.  G.  Smillie 

Studies  on  hookworm  infection  in  Brazil;  first  paper.  N.  Y., 
Rockefeller  Institute  for  Medical  Research,  1921.  (Monograph  no. 
14.) 

Technic  of  chenopodium  administration  in  hookworm  disease. 
Journal  of  the  American  Medical  Association,  Feb.  12,  1921,  v.  76, 
p.  419-420.     Same  reprinted. 

Ferrell,  J.  A. 

Careers  in  public  health  service.  Journal  of  the  American  Medical 
Association,  Feb.  19,  1921,  v.  76,  p.  489-492.     Same  reprinted. 

Measures  for  increasing  the  supply  of  competent  health  officers. 
Journal  of  the  American  Medical  Association,  Aug.  13,  1921,  v.  77, 
p.  513-516.     Same  reprinted. 


INTERNATIONAL    HEALTH    BOARD  1 57 

Gregg,  Alan 

Inspecgao  sanitaria  da  Commissao  Rockefeller  no  estadedoParana. 
Archives  paraenses  de  Medicina,  Curityba,  Jan.,  1921,  v.  1,  p. 273-276. 

Inspeccae  sanitaria  da  Commissao  Rockefeller  em  Santa  Catha- 
rina.  Archivos  paraenses  de  Medicina,  Curityba,  May,  1921,  v,  2, 
p.  11-16. 

GuiTERAS,  Juan 

Observations  on  yellow  fever  in  a  recent  visit  to  Africa.  Sanidad 
y  Beneficencia,  Habana,  Jan.-Mar.,  1921,  v.  25,  p.  34-43. 

Hackett,  L.  W. 

Os  cinco  annos  da  Commissao  Rockefeller  no  Brasil.  Boletim  da 
Academia  Nacionalde  Medicina^  Rio  de  Janeiro,  1921,  v.  93,  p.  62-73. 

Harrison,  A.  P. 

Oil  field  sanitation.  Texas  Municipalities^  Sept.-Nov.,  1921,  v.  8, 
p.  108-111. 

Hegner,  R,  W.  and  G.  C.  Payne 

Surveys  of  the  intestinal  protozoa  of  man  in  health  and  disease. 
Scientific  Monthly,  Jan.,  1921,  p.  47-52.     Same  reprinted. 

Lambert,  S.  M. 

Intestinal  parasites  in  North  Queensland.     Medical  Journal  oj 
Australia,  Apr.  23,  1921,  p.  332-335.     Same  reprinted. 
LePrince,  J.  A. 

Co-operative  anti-malaria  campaigns  in  the  United  States  in  1920. 
Southern  Medical  Journal,  Apr.,  1921,  v.  14,  p.  297-306. 

NoGucHi,  Hideyo 

Prophylaxis  and  serum  therapy  of  yellow  fever.  Journal  oj  the 
American  Medical  Association,  July  16,  1921,  v.  77,  p.  181-185. 

Recent  experimental  studies  on  yellow  fever.  American  Journal 
of  Hygiene,  Jan.,  1921,  v.  1,  p.  118-129.     Same  reprinted. 

NoGUCHi,  Hideyo  and  I.  J.  Kligler 

Experimental  studies  on  yellow  fever  in  northern  Peru.  Journal 
of  Experimental  Medicine,  Feb.  1,  1921,  v.  33,  p.  239-252.  Same 
reprinted. 

Immunology  of  the  Peruvian  strains  of  Leptospira  icteroides. 
Journal  of  Experimental  Medicine,  Feb.  1,  1921,  v.  33,  p.  253-260. 
Same  reprinted. 

NoGucHi,  Hideyo  and  Wenceslao  Pareja 

Prophylactic  inoculation  against  yellow  fever.     Journal  of  the 
American  Medical  Association,  Jan.  8,  1921,  v.  76,  p.  96-99. 
Sawyer,  W.  A. 

Hookworm  in  Australia.  Medical  Journal  of  Australia,  Feb.  19, 
1921,  p.  148-150.     Same  reprinted. 

Team  work  in  sanitation.  Medical  Journal  of  Australia,  Apr.  9, 
1921,  p.  285-287.     Same  reprinted. 


ISS      THE  kOCKEFELLER  FOUNDAtlON 

Sedgwick,  W.  T. 

Modern  medicine  and  the  public  health.  Public  Health  Reports, 
Jan.  28,  1921,  v.  36,  p.  109-116. 

Smillie,  W.  G. 

Comparison  of  the  number  of  hookworm  ova  in  the  stool  with  the 
actual  number  of  hookworms  harbored  in  the  individual.  American 
Journal  oj  Tropical  Medicine,  Nov.,  1921,  v.  1,  p.  389-395. 

SouzA,  G.  H.  DE  Paula 

Sanitary  propaganda  in  Brazil.  Bulletin  o/  the  Pan  American 
Union,  Apr.,  1921,  v.  52,  p.  364-366. 

Stuart,  Edward 

Popular  health  instruction.  International  Journal  oj  Public 
Health,  Mar.-Apr.,  1921,  v.  2,  p.  152-163. 

Van  Dine,  D.  L. 

The  destruction  of  anopheles  in  screened  dwellings.  Southern 
Medical  Journal,  Apr.,  1921,  v.  14,  p.  289-296. 

Vincent,  G.  E. 

Passing  of  the  country  doctor.  Forum,  Oct.,  1921.  Reprinted 
with  the  title,  Modern  tendencies  in  medical  education  and  practice. 

World  health  and  the  Rockefeller  Foundation.  Nation^s  Health, 
May,  1921,  v.  3,  p.  270-272. 

Warren,  A.  J. 

General  outline  of  a  comprehensive  plan  of  rural  health  work. 
Kansas  State  Board  of  Health,  Bulletin,  May,  1921,  v.  17,  p.  84-87. 

Williams,  L.  R. 

Some  problems  of  nursing  education.  New  York  State  Department 
of  Health,  Health  News,  Sept.,  1921,  v.  16,  p.  189-197. 

Willis,  H.  H. 

Simple  levitation  method  for  the  detection  of  hookworm  ova. 
Medical  Journal  of  Australia,  Oct.  29,  1921,  p.  375-376.  Same 
reprinted. 

Wyatt,  B.  L. 

Review  of  the  work  of  the  medical  bureau  of  the  Commission  for 
Prevention  of  Tuberculosis  in  France,  July  9,  1917 — Dec.  30,  1920. 
Paris,  1921. 


APPENDIX 


11 


ACKNOWLEDGMENT 

Extensive  use  has  been  made  of  the  following 
special  articles  and  reports  in  compiling  the  ap- 
pendix, particularly  the  sections  dealing  with 
hookworm  disease  and  malaria: 

"Investigations  on  the  control  of  hookworm  dis- 
ease," by  W.  W.  Cort,  D.  L.  Augustine,  J.  E.  Ackert, 
F.  K.  Payne,  and  G.  C.  Payne.  The  American  Jour- 
nal of  Hygiene,  Baltimore,  September-November, 
1921,  V.  1,  Nos.  5  and  6;  January,  1922,  v.  2,  No.  1; 
March,  1922,  V.  2,  No.  2. 

"Anti-Hookworm  Campaigns  in  Southern  India," 
by  J.  F.  Caius,  K.  S.  Mhaskar,  and  J.  F.  Kendrick. 
In  manuscript. 

"Report  Covering  Experiments  in  Malaria  Con- 
trol," by  C.  C.  Bass.     In  manuscript. 

In  certain  instances  the  authors'  own  words  have 
been  used.  The  Board  is  indebted  to  these  as  well 
as  to  many  other  members  of  the  staff  for  contri- 
butions in  the  form  of  reports  and  articles  which 
have  made  possible  the  following  statement  of 
findings  and  results. 


APPENDIX 


I 

EXTENT  AND  SEVERITY  OF  HOOKWORM 
DISEASE 

INVESTIGATIONS  IN  INDIA 

Early  in  1915  the  Indian  Research  Fund  Association  decided  to  devote 
a  share  of  its  attention  to  the  subject  of  hookworm  infection  in  India. 
Its  first  inquiry,  under  the  auspices  of  Colonel  Sir  Clayton  Lane,  was 
carried  out  in  the  tea  gardens  of  the  Darjeeling  district  during  the  win- 
ter months  of  1915  and  1916.  Later,  or  from  October,  1916,  to  March, 
1917,  a  similar  inquiry  was  conducted  among  the  coolies  collected  at  the 
emigration  depot  at  Negapatam,  In  April,  1917,  the  locale  of  the 
investigation  was  transferred  to  Dindigul  (see  map,  page  162),  and 
additional  work  was  undertaken  in  Trichinopoly  jail.  The  work  in  Din- 
digul was  closed  on  May  24,  1919,  and  the  staif  moved  to  Trichinopoly, 
where,  until  December,  1921,  they  continued  to  devote  themselves  ex- 
clusively to  investigations  into  the  prevalence  and  severity  of  hookworm 
infection  and  the  factors  necessary  for  its  control. 

Inauguration  of  Control  Operations.  The  early  investiga- 
tions having  satisfied  the  authorities  of  Madras  that  the  infection  brought 
about  much  physical  suffering  and  economic  loss  within  the  Presidency, 
Government  determined  to  carry  out  an  active  campaign  against  the 
disease.  Upon  invitation  the  Board  lent  medical  officers,  in  the  be- 
ginning Dr.  George  P.  Paul  and  later  Dr.  John  F.  Kendrick,  to  assist 
in  the  work,  and  on  April  7,  1920,  control  operations  were  undertaken 
at  the  Cannanore  jail.    This  piece  of  work  was  completed  on  June  26, 

1920,  and  the  following  month  examination  and  treatment  were  begun 
among  the  labor  forces  on  the  Wynaad-Nilgiri  tea  estates.  Effort  con- 
tinued here  until  November  15,  1920,  when  control  measures  were  in- 
augurated among  the  employes  of  the  Buckingham  and  Carnatic  mills 
in  the  city  of  Madras.  In  June,  1921,  the  staffs  of  Madras  and  Trichi- 
nopoly joined  hands  and  carried  out  two  experimental  campaigns  among 
coolies  of  the  Mudis  and  Kalyanapandal  tea  estates  in  the  Coimbatore 
district. 

Prevalence  of  Infection  in  Madras  Presidency.  From  the  in- 
ception of  the  work  in  Negapatam  in  1916  until  the  close  of  the  year 

1921,  a  total  of  19,239  persons  were  examined:  16,743  in  villages,  towns, 
and  rural  areas,  and  on  estates;  and  2,496  in  the  city  of  Madras.  In 
the  areas  exclusive  of  Madras  city,  97.1  per  cent  of  all  persons  ex^m- 

i6i 


1 62 


THE  ROCKEFELLER  FOUNDATION 


ined  were  found  to  harbor  hookworms;  in  Madras  city,  63.6  per  cent. 
Conditions  extremely  suitable  for  the  development  of  the  parasites  and 
the  spread  of  the  disease  were  encountered  practically  everywhere:  the 
country  is  tropical,  and  the  vast  majority  of  its  inhabitants  go  barefoot, 
live  away  from  sewerage,  and  work  in  the  soil. 

Severity  of  Infection  in  Madras  Presidency.  Although  the  in- 
vestigations indicated  that  nearly  everyone  in  the  Presidency  was  infected, 
all  classes  and  all  walks  of  life  were  not  infected  to  the  same  degree. 
Sweepers,  or  town  scavengers,  and  ryots  working  in  close  contact  with  the 
soil  were  found  to  harbor  six  times  as  many  worms  as  the  police,  and 


SORE 


C    H    I    T     T    O    O    R,. 


r'A/\  aJ    N     O     R      T     H<:  ^       ' 


"■OlRI 


DEVA'RSHOLA*; 


T        ^,      c      ;-■       A  \   ^TIRUNAGESWARAM 

*       ,A^  ^^       e         y*  sWamimalai 

O.MBATORE.      ^*    TRICh|^r(p'pOLY.|V-^^     .'JnAGORE 

Mub'lS^   ',  I  ^''s  ,       o      •/NEGAPATAM 

«•  •dInOigul  y 

PARJAMPATTI    •vAKt<AMPATTI. 


SOUTHERN  PART 

OF 

MADRAS  PRESIDENCY 

INDIA 

•  LOCALITIES  VISITED 


Fig.  40. — Localities  visited  in  investigation  into  the  incidence  and 
effects  of  hookworm  disease  in  Madras  Presidency,  India 


twelve  times  as  many  as  the  classes  who  spend  most  of  their  time  indoors. 
Among  most  classes  the  infection  seldom  produces  severe  symptoms,  as 
the  parasites  are  relatively  few  in  number  and  nearly  always  the  less 
harmful  Necators.  It  is  chiefly  to  estate  laborers  that  the  infection  brings 
an  appreciable  diminution  in  health  and  energy.  Since,  however,  the 
laboring  classes,  which  are  most  severely  infected,  make  up  the  bulk  of 
the  population,  the  country  must  suffer  in  the  aggregate  an  enormous  eco- 
nomic loss  from  the  effects  of  the  disease. 

The  following  paragraphs  give  a  brief  r6sum6  of  the  findings  in  the 
different  localities  investigated: 


INTERNATIONAL    HEALTH    BOARD  1 63 

a.  Inquiry  at  Negapatam.  Of  the  total  of  8,969  persons  examined 
in  the  investigations  conducted  at  Negapatam,  98.6  per  cent  of  the 
coolies  in  the  emigration  depot  were  found  infected  and  91.0  per  cent  of 
the  people  in  the  town.  Since  the  coolies  examined  were  drawn  from 
thirteen  districts  and  four  states  of  the  Madras  Presidency,  and  since  the 
infection  was  found  as  often  among  those  who  had  never  before  left  the 
country  as  among  those  who  were  emigrating  for  the  second  or  third  time, 
the  results  demonstrated  hookworm  disease  to  be  endemic  in  India. 
They  suggested  also  that  the  infection  was  universally  prevalent  in  rural 
areas  of  the  Trichinopoly,  Tanjore,  Malabar,  Madura,  and  South  Arcot 
districts  (see  map.  Fig.  40,  page  162). 

The  infection  occurred  in  all  classes  of  people  examined,  irrespective 
of  locality,  caste,  age,  sex,  or  occupation,  yet  it  was  noted  that  ova  were 
found  more  readily  in  specimens  from  the  depot  and  village  population 
than  in  those  from  residents  of  the  town.  Sixty-two  per  cent  of  the 
coolies  examined  at  the  depot,  practically  all  of  whom  harbored  hook- 
worms but  who  nevertheless  constituted  a  selected  group,  were  in  appar- 
ent good  health  and  an  additional  35  per  cent  in  fair  health.  Not  more 
than  3  per  cent  were  visibly  affected.  Among  the  children  of  the  town, 
however,  the  presence  of  hookworm  infection  was  unquestionably  respon- 
sible for  much  ill  health,  anemia,  and  retardation  of  physical  development. 

h.  Swamimalai-Tirunageswaram.  These  two  typical  villages  in  the 
Tanjore  district  were  selected  for  investigation  in  the  hope  of  gaining 
some  insight  into  the  incidence  of  the  infection  among  the  village  popu- 
lation of  India.  All  of  the  239  persons  examined  in  the  two  towns  were 
found  infected,  irrespective  of  sex,  age,  or  apparent  state  of  health.  The 
physical  condition  of  the  coolie  population  as  a  whole  was  poorer  than 
that  at  Negapatam.  Again  the  school  children  showed  marked  debility 
and  general  retardation. 

c.  Dindigul.  Dindigul  town  and  the  few  neighboring  villages  were 
next  chosen  for  observation.  Of  412  persons  microscopically  examined, 
including  sweepers,  police  constables,  factory  hands,  school  children, 
and  patients  in  hospital,  100  per  cent  were  found  infected.  Seventy-nine 
sweepers  harbored  an  average  of  127  worms  per  case;  fifty-two  police,  an 
average  of  twenty-one;  twenty-one  persons  of  the  upper  and  middle 
classes,  an  average  of  eleven.  On  the  whole  the  infection  was  light;  in 
the  main  the  worms  were  of  the  species  Necator. 

d.  Vakkampatti-Panjampatti.  Examination  of  250  fecal  specimens  in 
these  two  villages,  located  five  miles  from  Dindigul,  again  showed  100 
per  cent  infection  of  a  degree  that,  though  still  mild,  was  decidedly 
heavier  than  in  the  town. 

e.  Trichinopoly  jail.  Of  convicts  who  had  resided  in  the  southern 
part  of  Madras  Presidency,  ninety-seven  of  every  100  examined  were 
found  infected.  The  severity  of  the  infection  varied  widely  according  to 
districts,  the  average  number  of  worms  harbored  ranging  from  6.2  to 
102.8.  For  ten  selected  districts  the  average  complement  of  worms  har- 
bored was  sixty-two.  Here  again  the  worms  were  mainly  of  the  species 
Necator. 


164 


THE  ROCKEFELLER  FOUNDATION 


No  clear  relationship  was  discovered  between  the  hemoglobin  index 
and  the  number  of  hookworms  harbored,  and  no  justification  for  classifi- 
cation into  light,  mild,  and  severe  cases  on  the  basis  of  degree  of  anemia. 
Treatment  which  resulted  in  complete  elimination  of  the  parasites  raised 
the  hemoglobin  index  only  two-tenths  of  a  point,  or  from  an  average  of 

74.6  to  74.8.  It  was, 
however,  shown  fairly 
conclusively  that  free- 
dom from  hookworm 
disease  diminished  the 
susceptibility  to  bowel 
complaints  and  influ- 
enza, shortened  the 
period  of  illness  from 
these  diseases,  and 
lowered  the  death  rate 
(see  Fig.  41).  There 
was,  moreover,  in  the 
matter  of  gain  in 
weight,  a  slight  differ- 
ence in  favor  of  treated 
cases,  72.2  per  cent  of 
them  showing  a  gain 
as  compared  with  66.3 
per  cent  of  untreated 
cases. 

Study  of  the  records 
for  1,878  prisoners 
brought  out  the  inter- 
esting fact  that  while 
the  incidence  of  hook- 
worm infection  is  not 
appreciably  affected  by 
jail  life  even  under 
sanitary  conditions,  a 
natural  progressive 
elimination  of  worms 
takes  place  that  does 
very  markedly  affect 
the  intensity  of  the  dis- 
ease. Thus,  an  aver- 
age infection  of  fifty- 
eight  worms  on  admission  fell  to  forty-eight  among  inmates  of  a  month 
and  to  thirty-two,  twenty-nine,  and  seventeen  worms,  respectively, 
among  inmates  of  three,  twelve,  and  eighteen  months.  After  eighteen 
months  the  average  number  of  hookworms  per  case,  though  low,  remained 
nevertheless  fairly  constant,  even  so  long  a  stay  as  seventeen  years  failing 
^o  bring  elimination  of  all  the  worms. 


200 

■■  NOT  TREATED 

ZM  TREATED 

150 

1 

j.oo 

1- 

w      50 

0 

1 

1 

i 

i 

I 

AVERAGE 
POPULATION 

550 

553 

724 

654 

522 

682 

452 

935 

TOTAL 
CASES 

112 

64 

140 

69 

65 

19 

40 

13 

TOTAL 
DEATHS 

10 

5 

8 

0 

1 

0 

0 

0 

)dfe»^^OF 

14.1 

15.6 

15.1 

10.7 

14.2 

9.2 

14.8 

9.4 

ILLNESS.  DAYS 

YEAR 

1918 

1919 

1920 

1921      1 

Fig.  41. — Incidence  of  bowel  complaints, 
Trichinopoly  jail,  India,  1918  to  1921,  inclu- 
sive. Among  prisoners  who  had  not  been 
treated  for  hookworm  disease,  sickness  and 
deaths  from  bowel  complaints  were  much  more 
frequent  than  among  those  who  had  been 
treated 


INTERNATIONAL    HEALTH    BOARD 


l6S 


/.  Coimhatore  jail.  During  an  interval  in  the  work  in  Trichinopoly 
jail  brought  about  by  an  epidemic  of  cholera,  the  stools  of  463  prisoners 
in  the  Coimbatore  jail  were  examined  for  hookworm  ova  and  the  hemo- 
globin indices  determined  in  300  cases.  The  rate  of  hookworm  infec- 
tion was  87.5  per  cent;  the  average  hemoglobin  index,  72.4.  The  few 
figures  collected  showed  again  that  a  prolonged  stay  under  the  sani- 
tary regimen  of  jail  life  brought  down  the  intensity  of  hookworm  in- 
fection but  in  no  case  eliminated  it. 
There  was  no  opportunity,  however, 
as  at  Trichinopoly,  for  investigating 
the  effect  of  treatment  in  improv- 
ing the  physical  condition  of  the 
convicts. 

g.  Cannanorg  jail.  Microscopic  ex- 
amination of  the  964  inmates  of 
Cannanore  jail,  drawn  mostly  from 
the  wet  districts  of  Malabar  and  South 
Canara,  revealed  a  rate  of  infection 
of  89.7  per  cent.  The  incidence  among 
new  arrivals  is  probably  nearer  99  per 
cent,  for  examination  of  197  specimens 
obtained  from  persons  lately  admitted 
to  the  jail  showed  ova  in  196,  or  99.5 
per  cent.  Only  a  few  cases  presented 
clinical  manifestations  of  severe  or 
even  moderately  severe  hookworm  in- 
fection. The  large  number  of  infected 
convicts  were  freed  of  their  worms  in  a 
short  time  by  a  small  staff  administer- 
ing systematic  treatment. 

h.  Manantoddy-Devarshola.  On 
these  estates  examination  of  about 
2,300  coolies  gathered  from  diverse 
parts  of  the  Presidency  showed  100 
per  cent  hookworm  infection  among 
coolies  from  wet  districts  and  83  per 
cent  among  those  from  dry.  Hemo- 
globin estimations  made  on  200  of  the 
coolies  revealed  an  index  of  60.0. 
Most  of  these  estate  coolies  were  in 
pitiful  physical  condition. 

i.  City  of  Madras.  Among  1,782  persons  examined  at  the  Carnatic 
mills  in  the  city  of  Madras,  the  general  rate  of  infection  was  64.5  per  cent. 
Among  clerical  workers  It  was  only  18.4  per  cent.  Of  609  persons  exam- 
ined at  the  joint  school  of  the  Buckingham  and  Carnatic  Mills,  the 
teachers,  who  wear  shoes,  were  15.8  per  cent  infected,  and  the  pupils,  who 
go  barefoot,  55.7.  In  the  Chingleput  town  reformatory  88.6  per  cent  of 
the  245  persons  examined  were  found  infected. 


Fig.  42. — Worms  harbored  by 
1,878  prisoners  examined  in 
Trichinopoly  jail,  India,  grouped 
according  to  length  of  stay  in 
jail.  Natural  progressive  elimi- 
nation of  worms  takes  place  as 
the  period  of  jail  residence 
lengthens,  the  opportunities  for 
acquiring  additional  heavy  in- 
fection being  limited 


1 66  tttE   ROCKEFELLER   FOUNDATION 

Signs  of  severe  hookworm  disease  were  seldom  seen  at  tiie  mills;  only 
seventeen  cases  of  profound  anemia  were  observed,  and  these  improved 
rapidly  under  treatment.  Sanitary  latrines,  provided  in  sufficient  num- 
bers and  in  convenient  places  at  the  mills,  are  unquestionably  a  factor  in 
keeping  down  the  infection.  Elsewhere  in  the  city  of  Madras  gross  soil 
pollution  occurs,  especially  around  the  huts  and  tenements.  In  a  section 
of  the  city  containing  several  hundred  one-room  tenements,  inspection 
disclosed  only  one  latrine. 

y.  Mudis  tea  estates.  On  this  group  of  five  tea  estates,  located  seventy 
miles  south  of  Coimbatore,  microscopic  examination  of  794  coolies,  for 
the  most  part  recruited  from  the  plains  of  Madras  Presidency,  revealed 
91.6  per  cent  infected;  examination  by  treatment  and  recovery  of  worms 
revealed  100  per  cent  infected.  The  number  of  worms  harbored  by 
seventy-four  coolies  whose  worms  were  saved  after  treatment  ranged 
by  provinces  from  21.5  to  205.7  per  person,  an  average  of  92.9  (see  Fig. 
45,  page  170),  Hemoglobin  estimates  on  1,558  coolies  revealed  an  average 
index  of  74.8,  with  10  per  cent  of  the  cases  lower  than  50.  Here  again 
no  correlation  was  found  between  the  hemoglobin  index  and  the  number 
of  hookworms  harbored. 


INCIDENCE  IN  AUSTRALIAN  TERRITORY 

By  the  end  of  the  year  1921  all  of  the  projects  contemplated  in  the  origi- 
nal plan  for  the  control  of  hookworm  disease  in  Australia,  embracing 
surveys  or  control  operations  in  every  Australian  state  and  in  the  three 
territories,  were  under  way.  Surveys  were  completed  during  1920  or 
1921  in  Tasmania,  in  New  South  Wales,  in  Victoria,  in  the  British  Solo- 
mon Islands  adjacent  to  Papua,  and  in  additional  areas  in  the  state  of 
Queensland.  Results  to  date  indicate  that  Western  Australia  as  well  as 
an  area  in  Northern  Territory  centering  in  Darwin  is  entirely  free  of 
hookworm  infection. 

Victoria  and  Tasmania.  In  the  survey  of  the  state  of  Victoria 
no  hookworms  were  found  among  the  1,629  persons  examined.  The 
mines  were  as  free  of  infection  as  the  surface,  where  climatic  conditions, 
particularly  lack  of  rain,  are  unfavorable  to  the  development  of  larvae. 
In  Tasmania  2,209  fecal  examinations  revealed  only  two  cases  of  hook- 
worm infection,  both  in  persons  who  had  arrived  from  Fiji  during  the 
preceding  seven  months.  The  general  climatic  conditions  of  this  state 
also  are  considered  unfavorable  to  the  development  of  hookworm  larvae. 

State  of  Queensland.  During  the  year  1921  surveys  were  com- 
pleted in  nine  areas,  including  the  Cloncurry-Hughenden,  Longreach- 
Emerald,  and  Charlevllle-Dalby  districts,  which  cover  about  500,000 
square  miles  and  embrace  most  of  the  interior  of  Queensland. 

Examination  of  2,120  persons  in  the  Cloncurry-Hughenden  area 
showed  only  fourteen,  or  0.66  per  cent,  infected,  and  all  of  these  fourteen 
had  received  their  infection  in  other  regions.  The  conditions  here  with 
respect  to  rainfall  are  particularly  unfavorable  for  the  development  and 


Fig.  43. — Ancient  temples  in  Siam  put  at  service  of 
hookworm  commission  as  headquarters  for  meetings  and 
distribution  of  Hterature.  Educational  activities  are  an 
essential  feature  of  the  world-wide  crusade  against  hook- 
worm disease 


ijimii^- 


Fig.  44. — Groups  of  natives  assembled  for  treatment, 
Tupile,  Panama.  Hookworm  campaigns  aiford  an  excel- 
lent means  of  instructing  primitive  peoples  in  the  rudiments 
of  sanitation 


INTERNATIONAL  HEALTH    BOARD  1 69 

spread  of  the  disease.  In  fact,  the  whole  area  would  seem  to  be  definitely 
non-infectible. 

In  the  Longreach-Emerald  area  examination  of  759  children  at 
selected  state  schools  revealed  nine  cases  of  hookworm  disease,  or  a  per- 
centage of  1.2.  The  low  rainfall,  producing  dry  soil  conditions  which 
interfere  with  the  development  of  the  larvae,  and  the  large  tracts  of  land 
held  for  pasture,  with  only  an  insignificant  acreage  under  cultivation,  are 
believed  to  be  responsible  for  the  low  incidence.  The  survey  demon- 
strated that  the  disease  is  almost  certainly  absent  from  the  surface;  the 
coal  mines  near  Clermont,  however,  were  not  investigated. 

In  the  Charleville-Dalby  area  535  school  children  were  examined 
and  none  were  found  infected.  Here  again  low  rainfall  was  chiefly  re- 
sponsible for  the  absence  of  indigenous  hookworm  disease. 

Investigations  were  also  carried  out  in  a  small  area  of  fifty-nine  square 
miles  centering  in  the  city  of  Rockhampton,  Queensland.  In  this  sur- 
vey 4,931  persons  were  examined  and  only  1.03  per  cent  found  to  be  in- 
fected— a  rate  too  low  to  call  for  control  operations.  The  low  incidence 
in  the  Rockhampton  district  is  explained  by  the  fact  that  the  city  has 
an  efltective  system  of  night  soil  disposal,  while  the  district  as  a  whole 
has  little  rainfall  and  but  a  small  proportion  of  its  total  area  under 
cultivation.  The  natives  of  Hammond  Island,  near  Thursday  Island, 
were  examined  and  found,  owing  to  their  habit  of  living  on  the  beach, 
to  be  entirely  free  of  hookworm  infection.  In  an  area  including  Bris- 
bane and  vicinity  the  rate  of  infection  recorded  was  only  1.4  per  cent, 
and  worm  counts  revealed  the  average  severity  also  to  be  low.  Only 
one  small  region  in  the  state  of  Queensland  remains  to  be  visited  by  the 
survey  staff — an  area  with  a  small  population  located  at  the  southern 
end  of  the  gulf  of  Carpentaria. 

Papua.  The  territory  of  Papua,  surveyed  in  1917  by  Dr.  J.  H. 
Waite,  was  again  surveyed  in  1920  by  Dr.  S.  M.  Lambert.  The  investi- 
gation, covering  the  seven  months  from  May  14  to  December  15,  dis- 
closed a  high  rate  of  hookworm  infection  as  far  as  the  survey  staff  was 
able  to  penetrate  the  country. 

The  total  population  of  the  821  villages  under  government  control  is 
estimated  at  50,000  and  in  addition  there  are  7,000  indentured  laborers 
in  the  colony.  The  entire  population,  with  the  exception  of  a  few  whites, 
consists  of  native  Papuans.  The  staff  examined  6,141  indentured  and 
633  casual  laborers  on  sixty  plantations;  10,372  natives  In  166  villages; 
and  759  natives  in  nine  mission  schools.  On  the  plantations  the  rate  of 
infection  was  65.8;  in  the  villages,  54.9;  at  the  mission  schools,  59.7. 
Among  the  ninety-two  white  residents  examined,  only  17  per  cent  in- 
fection was  recorded. 

There  was  little  difference  In  the  rate  or  the  severity  of  Infection  be- 
tween the  villages  and  the  plantations:  the  average  village  rate  of  in- 
fection was  only  11  points  lower  than  the  average  plantation  rate. 
Grouped  geographically  the  plantation  rates  ranged  from  62.2  to  84.5 
per  cent,  being  highest  in  the  Delta  division,  where  rainfall  and  tempera- 
ture are  high  and  there  Is  gross  soil  pollution.     The  village  rates  ranged 


170 


THE  ROCKEFELLER  FOUNDATION 


from  33.5  to  79.7  per  cent.  Marked  contrast  existed  between  the  in- 
fection rates  of  villages  in  the  dry  and  wet  regions,  the  average  being 
13.1  for  the  dry  and  70.9  for  the  wet. 

Hemoglobin  estimates  on  2,891  infected  and  835  non-infected  natives 
showed  the  average  index  of  the  infected  group  to  be  55.7  as  compared 
with  63.5   for  the   non-infected.    The  low   hemoglobin   index   of  the 

non-infected  group  is  be- 
lieved to  be  due  in  the 
main  to  malaria,  a  disease 
with  which  practically  all 
Papuans  are  infected. 
Clinical  hookworm  disease 
existed  in  only  5  to  10  per 
cent  of  the  natives  ex- 
amined. Estate  managers 
report  that  marked  benefits 
in  health  and  strength  have 
resulted  from  the  course  of 
treatment  administered  as 
a  feature  of  the  survey. 


INVESTIGATION  IN 
CHANGWAT  LAM- 
PANG,  SIAM 

Under  the  new  plan  of 
organization  adopted  for 
Siam,  survey  units,  operat- 
ing from  strategic  centers, 
are  starting  out  to  cover  the 
country  in  an  effort  to  as- 
certain the  prevalence  and 
severity  of  hookworm  infec- 
tion and  to  assist  the  local 
authorities  in  developing 
among  the  people  a  sanitary 
sense.  One  such  survey — 
that  in  the  changwat  Lam- 
pang,  mondhol  Maharat — 
was  in  progress  from  June 
7  to  September  9,  1921.  Estimates  based  on  the  results  of  the  survey 
indicate  that  approximately  200,000  of  the  275,000  people  living  in  the 
changwat  harbor  hookworms. 

Examination  of  4,038  persons  revealed  an  infection  rate  of  75.0  per 
cent;  in  the  four  aumphurs  in  which  examinations  were  made,  the 
rates  were  74,  71,  70,  and  85  per  cent.  Among  the  general  popula- 
tion the  infection  rate  was  74.9;  among  school  children  71.7;  among 


Fig.  45. — Average  number  of  worms 
harbored  by  seventy-four  coolies  at  work 
on  the  Mudis  tea  estates,  Madras  Presi- 
dency, India,  grouped  according  to  the 
coolies'  districts  of  origin.  Those  from 
Coimbatore  were  almost  entirely  of  the 
uncleanly  Panchama  class 


INTERNATIONAL  HEALTH   BOARD 


171 


prisoners  73.9;  among  gendarmes  78.3;  and  among  soldiers  78.2  per 
cent. 

The  infection  was  of  a  moderate  degree  of  severity.  From  355  cases 
whose  stools  were  saved  for  seven  hours  after  treatment,  a  total  of 
8,181  hookworms  were  obtained,  or  an  average  of  twenty-three  worms  per 
case.  The  largest  number  of  worms 
expelled  by  any  one  person  was  251. 
Hemoglobin  determinations  made  on 
503  school  children  gave,  it  is  true,  a 
low  average  index — 74.5 — but  this 
was  due  to  various  contributing 
causes,  including,  in  addition  to  hook- 
worm, malaria  and  malnutrition. 


CONTROL   EFFORT   IN 
BRITISH  HONDURAS 

An  infection  survey  carried  out  in 
British  Honduras  from  February  7 
to  May  24,  1916,  under  the  direction 
of  Dr.  L.  W.  Hackett,  who  was  lent 
for  the  purpose  by  the  Board,  awak- 
ened considerable  interest  among  the 
people,  and  on  September  15,  1917, 
systematic  examination  and  treatment 
were  begun.  Through  courtesy  of 
Government  the  Board  has  received  a 
copy  of  the  report  of  the  campaign, 
prepared  by  Thomas  Gann,  the  medi- 
cal officer  in  charge,  showing  results 
accomplished  up  to  May,  1921. 

Approximately  15,000  of  the  colony's 
total  population  of  40,458  live  in  local- 
ities where  the  infection  is  so  low 
as  not  to  necessitate  treatment.  Of 
the  remaining  population,  practically 
four-fifths  have  been  reached  by  the 
treatment  staff.  Resurveys  made 
during  1920  of  districts  whose  inhabitants  were 
years  previously,  show  substantial  reduction  in 
fection. 

The  excellent  results  accomplished  toward  stamping  out  the  disease 
are  due  in  no  small  degree  to  the  stress  that  has  been  laid  on  soil 
sanitation.  From  the  beginning  police  and  health  authorities  have 
insisted  upon  the  provision  of  suitable  latrine  accommodation,  until  it 
may  be  said  that  at  present  nearly  every  place  in  the  colony  is  provided 
with   adequate  sanitary  latrines.     The  exceptions  are  certain  remote 


Fig.  46. — Average  daily  num- 
ber of  patients  in  Lionel  Town 
hospital,  Vere  area,  Jamaica, 
1918-1921,  inclusive.  Follow- 
ing the  anti-hookworm  cam- 
paign in  this  area  in  1920  there 
was  a  significant  reduction  in 
hospital  cases 


treated  two  or  more 
the  incidence  of  in- 


172 


THE  ROCKEFELLER  FOUNDATION 


Carib  and  Indian  villages,  some  small  settlements  of  a  few  houses  each, 
and  lumber  and  other  camps  composed,  usually,  of  only  temporary 
habitations. 


SURVEYS  IN  MISCELLANEOUS  AREAS 

Upon  resumption  of  the  campaign  in  Dutch  Guiana,  investigation 
in  the  area  selected  for  initial  control  operations  showed  92.2  per  cent 

infection.  A  complement  of 
from  300  to  400  worms  was  not 
unusual;  two  persons  after  a 
single  treatment  expelled  more 
than  1,300  worms.  From  the 
republic  of  Colombia  high 
rates  of  infection  continue  to 
be  reported,  the  average  for  the 
areas  embraced  within  the  con- 
trol program  of  the  year  being 
92  per  cent.  In  QuebradlUas, 
the  first  area  to  be  worked  under 
the  new  plan  of  control  ap- 
proved for  Porto  Rico,  an 
infection  rate  of  86.2  per  cent 
was  recorded  among  the  7,107 
persons  examined.  Many  severe 
cases  were  noted,  though  worm 
counts  and  hemoglobin  estima- 
tions do  not  reveal  a  very  severe 
general  Infection.  In  Jamaica 
an  average  infection  rate  of  39 
per  cent  is  reported  for  the  dis- 
tricts worked  during  the  years 
1920  and  1921.  In  this  colony 
a  striking  difference  is  reported 
in  the  infection  rates  for  wet 
and  dry  districts,  the  average 
being  85  per  cent  for  the  former 
and  only  10  per  cent  for  the 
latter.  The  Infection  rate  for  the 
British  Solomon  Islands,  just 
surveyed,  is  reported  as  24.7. 


100 
80 

§  SO 
z 

z 

§ 

o 

20 
0 

^^ 

EXAMINED 

32- 

,25 

S 

65 

85 

DATE 

DEC. 
1920 

NOV. 
1921 

Fig.  47. — Effect  of  hookworm 
treatment  administered  in  the  Rio 
Cobre  Home,  Jamaica.  The  inci- 
dence of  hookworm  infection  among 
the  inmates  was  reduced  and  the 
hemoglobin  index  raised 


BENEFITS  OF  HOOKWORM  TREATMENT 
Improvement  in  Health  and  Physical  Condition,  Jamaica 

Statistics  for  the  Lionel  Town  hospital  In  Jamaica,  an  institution 
which  serves  the  estates  and  villages  of  the  Vere  area,  where  operations 
for  the  control  of  hookworm  disease  were  carried  out  between  November, 


INTERNATIONAL    HEALTH    BOARD 


173 


1919,  and  April,  1920,  show  that  during  1918  and  1919  the  average 
daily  number  of  patients  was  seventy-eight,  and  during  1920,  seventy- 
two.  In  1921,  following  a  campaign  against  hookworm  disease  in  the 
area,  it  dropped  to  fifty-seven — a  decrease  in  one  year  of  20.8  per  cent 
(see  Fig.  46,  page  171).  Before  1920  more  than  80  per  cent  of  the  patients 
admitted  to  the  hospital  were  infected 
with  hookworm  disease,  as  compared 
with  not  more  than  5  per  cent  during 
1921. 

At  another  institution  in  Jamaica, 
the  Rio  Cobre  Home,  thirty-two  chil- 
dren out  of  the  seventy-two  examined 
in  December,  1920,  had  hookworm 
disease;  in  November,  1921,  following 
a  campaign  against  the  disease  in 
which  all  infected  children  received 
treatment,  only  eleven  out  of  sixty 
examined  were  found  to  be  infected. 
Meanwhile  the  average  hemoglobin 
of  all  children  in  the  institution  had 
risen  from  65  to  85,  an  increase  of 
30.8  per  cent  (see  Fig.  47,  page  172), 
and  the  average  weight  had  increased 
from  46.5  to  51.6  pounds,  or  11.0  per 
cent.  Twenty-five  of  the  children 
examined  in  1921  were  among  the 
group  of  thirty-two  who  were  cured 
of  hookworm  disease  a  year  before, 
and  eight  of  them  were  found  to  have 
been  re-infected — a  re-infection  rate  of 
32  per  cent. 


Increased  Efficiency  of 
Sumatran  Laborers 


Fig.  48. — Hemoglobin  indices 
of  18,514  persons  in  Costa  Rica. 
Compare  index  of  the  group  not 
infected  with  hookworm  disease 
with  that  of  the  infected  per- 
sons before  treatment  as  well  as 
after  cure.  In  this  country  in- 
creased appetite,  blood  regen- 
eration, and  improved  health 
promptly  followed  treatment 
for  hookworm  disease 


Recent  official  government  corre- 
spondence from  Mauritius  calls  atten- 
tion to  the  fact  that  by  means  of 
control  measures  in  Sumatra  during 
the  period  from  1906  to  1918  the 
proportion  of  first-class  coolies  (those 

not  infected,  or  only  lightly  infected,  with  hookworms)  rose  from 
35  to  90  per  cent,  while  that  of  moderately  infected  coolies  fell  from 
50  to  10  and  that  of  severely  infected  from  15  to  0.5  per  cent.  The  number 
of  badly  infected  coolies  on  insanitary  estates  in  this  colony  averaged 
ten;  on  sanitary  estates,  three.  The  sanitary  estates  showed  1.8  per 
cent  of  coolies  sick;  the  insanitary,  3  per  cent. 

Three  estates  in  Sumatra  which,  in  spite  of  all  recommendations, 


174      THE  ROCKEFELLER  FOUNDATION 

refused  to  adopt  hookworm  control  measures,  had  in  the  course  of  two 
and  one  half  years  4,657  admissions  to  hospital.  Three  other  estates 
with  a  laboring  force  of  the  same  size  which  did  adopt  these  measures 
had  only  1,034  admissions — a  difference  of  78  per  cent.  One  hospital 
admission  represented  on  the  average  twenty-two  days  of  treatment, 
which,  reckoned  at  fifty  cents  a  day,  meant  an  aggregate  loss  of  no  less 
than  40,000  guilders  during  a  period  of  only  two  and  one  half  years. 


II 

LIFE  OF  HOOKWORM  EGGS  AND  LARVAE  IN 
THE   SOIL 

The  department  of  medical  zoology  of  the  School  of  Hygiene  and 
Public  Health  of  the  Johns  Hopkins  University  dispatched  to  the  island 
of  Trinidad,  British  West  Indies,  during  the  summer  of  1921,  an  expedi- 
tion to  study  the  life  of  hookworm  eggs  and  larvae  in  the  soil.  The 
expedition  was  under  the  direction  of  Dr.  William  W.  Cort  of  Johns  Hop- 
kins University  and  was  aided  by  a  subvention  from  the  Board.  Those 
who  took  part  in  the  investigation  included  Dr.  James  E.  Ackert  of  the 
Kansas  State  Agricultural  College,  Mr.  Donald  L.  Augustine  of  Johns 
Hopkins  University,  Dr.  George  C.  Payne,  the  Board's  director  in  Trini- 
dad, and  his  wife,  Dr.  Florence  King  Payne.  The  party  from  the  United 
States  sailed  from  New  York  May  5  and  returned  September  17.  The 
work  was  conducted  with  the  active  co-operation  of  the  Government 
ancylostomiasis  commission  and  was  carried  out  at  Princes  Town,  in  the 
south  central  part  of  the  island  in  an  area  where  sugar-cane  cultivation 
predominates  and  over  70  per  cent  of  the  people  are  hookworm  infected. 

Finding  of  Unsheathed  Hookworm  Larvae  in  the  Soil.  Al- 
though various  investigators  have  reported  that  under  certain  conditions 
mature  hookworm  larvae  may  lose  their  sheaths  while  still  living  in  the 
soil,  the  general  opinion  has  prevailed  that  they  normally  pass  this  period 
of  their  existence  enclosed  in  sheaths  and  complete  their  second  larval 
molt  only  when  penetrating  the  human  skin.  Both  field  and  laboratory 
studies  in  Trinidad  showed,  however,  that  it  is  a  common  occurrence  for 
mature  hookworm  larvae  to  lose  their  sheaths  while  continuing  to  live  in 
the  soil.  The  loss  of  sheath,  moreover,  did  not  render  the  larvae  non- 
infective. 

Of  a  total  of  4,265  mature  larvae  isolated  from  a  series  of  108  positive 
soil  samples  taken  from  an  area  of  a  sugar-cane  field  heavily  polluted  by 
individuals  infected  with  hookworms,  only  42  per  cent  were  enclosed 
within  the  protective  sheath.  The  finding  was  further  supported  by  the 
studies  of  conditions  under  which  hookworm  eggs  hatch  and  develop 
and  of  the  migration  of  infective  larvae,  both  of  which  showed  that  a 
proportion  of  the  larvae  became  unsheathed  while  in  the  soil.  The 
discovery  will  doubtless  call  for  a  revision  of  many  former  ideas  that 
have  resulted  from  a  study  of  sheathed  forms. 

Length  of  Life  of  Larvae  in  the  Soil.  The  discovery  that  so 
large  a  proportion  of  the  larvae  shed  their  skins  while  still  living  in  the 
soil  introduces  a  new  factor  for  consideration  in  determining  the  length  of 
larval  life.  Under  favorable  conditions  this  molting  was  not  found  to 
shorten  the  life  of  the  larvae,  although  in  unfavorable  environments  it 

175 


176      THE  ROCKEFELLER  FOUNDATION 

did  seem  to  decrease  somewhat  their  chances  of  survival.  Tropical  tem- 
perature and  other  environmental  conditions  which  tend  to  increase  the 
activity  of  the  mature  hookworm  larvae  were  found  to  shorten  their 
lives  through  the  more  rapid  using-up  of  the  stored  food  material. 

The  Trinidad  investigations  showed  that  the  life  of  larvae  in  the  soil 
seldom  exceeds  six  or  seven  weeks.  Heretofore  it  had  been  believed  that 
under  favorable  conditions  of  temperature  and  moisture  they  lived  for 
months  or  even  years.  In  the  cane-field  area,  where  there  was  intense 
soil  infestation,  the  number  of  larvae  was  reduced  more  than  90  per  cent 
within  three  weeks  after  soil  pollution  was  stopped,  only  a  very  few  larvae 
being  left  at  the  end  of  six  weeks.  Laboratory  experiments  with  differ- 
ent soils  under  different  conditions  showed,  too,  a  great  reduction  in  the 
number  of  larvae  in  two  or  three  weeks  and  an  almost  complete  dying 
out  in  six  weeks. 

Relation  of  Chickens  to  Spread  of  Hookworm  Disease.    So 

far  as  Trinidad  at  least  is  concerned  the  expedition  reported  that  chick- 
ens help  to  limit  rather  than  to  spread  the  disease.  The  great  majority 
of  hookworm  eggs  ingested  by  chickens  failed  to  produce  infective  hook- 
worm larvae  after  passing  through  the  chickens'  alimentary  tracts,  the 
failure  being  attributed  in  part  to  the  breaking  of  eggs  in  the  gizzards, 
to  injury  from  urine  in  the  chicken  feces,  and  to  malnutrition  of  the  larvae. 
Although  chickens  that  have  swallowed  hookworm  eggs  day  after  day 
may  establish  dangerous  infective  spots  around  drinking  receptacles; 
although  they  may  carry  eggs  and  larvae  from  places  unfavorable  for 
their  development  and  deposit  them  in  favorable  environments;  and  al- 
though they  may  transport  to  dooryards  and  other  places  traversed  by 
barefooted  persons  human  stools  voided  in  out-of-the-way  localities,  the 
reduction  of  mature  hookworm  larvae  brought  about  by  the  fowls  was 
nevertheless  found  to  be  more  than  sufficient  to  offset  the  establishment 
of  these  additional  infective  spots. 

Relation  of  Pigs  to  Spread  of  Hookworm  Disease.  The  dis- 
covery of  a  new  species  of  hookworm  {Necator  suillus)  as  being  of  com- 
mon occurrence  in  the  domestic  pigs  of  Trinidad  marked  the  study  of  the 
r61e  played  by  pigs  in  disseminating  the  infection.  The  investigation 
showed,  moreover,  that  the  pig,  ranging  freely,  is  an  important  factor  in 
the  spread  of  hookworm  infection.  A  high  percentage  of  human  hook- 
worm eggs  ingested  by  pigs  were  found  to  produce  infective  larvae,  the 
hatching,  during  the  rainy  season  in  Trinidad,  usually  occurring  within 
five  days. 

Effect  of  Hookworm  Control  Measures.  To  determine  the 
sources  of  human  infection  and  to  learn  the  eifect  of  a  control  campaign 
on  soil  pollution,  on  soil  infestation,  and  on  human  infection,  an  intensive 
epidemiologic  study  was  made  of  an  area  in  a  sugar  estate.  Of  146 
East  Indians  and  negroes  living  In  the  area  chosen  for  study,  117,  or  82.4 
per  cent,  were  found  to  be  infected  with  hookworms.  A  series  of  three 
treatments  greatly  decreased  the  proportion  of  persons  infected  as  well 
as  the  total  number  of  worms  harbored, 


Fig.  49. — Group  assembled  to  hear  lecture  and  receive 
treatment  for  hookworm  disease,  Fusagasuga,  Colombia 


Fig.  50. — Exhibit  on  hookworm  disease  at  the  National 
Agricultural  Exposition,  Brisbane,  Australia 


Fig.  51. — Negro  family,  residents  of  Federal  District, 
Brazil.  All  except  mother  treated  in  1919  for  hookworm 
disease.  Mother  first  treated  in  1921,  expelled  123  hook- 
worms; other  members  of  family,  re-treated  in  1921,  ex- 
pelled average  of  six  worms 


Fig.  52. — Examining  board  and  other  apparatus  used  in 
Jamaica  in  examining  fecal  specimens  by  the  salt-flotation 
process.  Great  speed,  accuracy,  and  economy  are  resulting 
from  this  and  other  improved  methods  of  diagnosis 


INTERNATIONAL  HEALTH   BOARD  1 79 

First  inspection  showed  soil  pollution  in  the  area  to  be  widespread  and 
gross,  though  concentrated  at  certain  easily  accessible  places  in  the  cane 
fields  near  the  barracks.  Soil  samples  showed  little  soil  infestation  ex- 
cept along  the  heavily  polluted  strip  of  cane.  The  building  of  adequate 
latrines  and  the  carrying  on  of  an  educational  campaign  effected  great 
reduction  in  pollution  in  the  cane  field.  A  series  of  soil  samples  taken  at 
intervals  showed  a  rapid  dying  out  of  infective  hookworm  larvae,  so  that 
in  about  six  weeks  soil  infestation  was  practically  eliminated. 

Examination  of  soil  samples  indicated  that  even  if  moisture  was  pres- 
ent, conditions  on  the  clay  loam  soil  were  not  favorable  for  the  develop- 
ment of  hookworm  larvae  unless  there  was  considerable  protection, 
especially  by  vegetation;  and  an  analysis  of  the  habits  of  the  people  in  rela- 
tion to  the  distribution  of  soil  infestation  suggested  that  most  of  the  heavy 
infection  was  due  to  the  practice  of  defecating  at  selected  places  in  the 
cane  field.  The  localized  character  of  soil  infestation,  especially  in  the 
cane  field,  showed  that  there  was  little  migration  of  infective  larvae, 
although  there  was  evidence  that  the  larvae  could  be  carried  considerable 
distances  by  water. 

Epidemiologic  Study  on  Cacao  Estate.  Examination  of  the 
people  living  in  three  houses  on  a  cacao  estate  showed  a  heavy  infection 
with  hookworms.  As  in  the  case  of  the  sugar  estate,  pollution  of  the 
soil  was  confined  almost  entirely  to  definite  spots,  "natural  latrines," 
in  the  cacao  grove  near  the  barracks.  Here,  again,  examination  of  soil 
samples  demonstrated  that  the  larvae  did  not  migrate  and  that  almost 
all  the  human  infection  was  derived  from  visits  to  the  natural  latrines. 
Even  in  this  grossly  polluted  strip  of  soil,  however,  the  findings  were  some- 
what irregular,  indicating  that  conditions  were  not  always  favorable  for 
the  larvae  to  develop.  Six  weeks  after  three  routine  treatments  had  been 
given,  soil  samples  taken  from  the  former  heavily  polluted  spots  showed 
marked  reduction  of  soil  infestation. 

Migration  of  Larvae  in  SoiL  Studies  of  migration  showed  defi- 
nitely that  hookworm  larvae  do  not  move  from  their  original  place  of 
development  unless  carried  away  by  the  action  of  water  or  on  the  feet  of 
man  or  one  of  the  domestic  fowls  or  animals.  Larvae  placed  on  moist 
soils  did  not  migrate  in  periods  of  from  fifteen  hours  to  forty-two  days. 
Not  only  did  they  not  migrate  even  when  their  environment  became 
unfavorable,  but  in  the  course  of  the  experiment  there  was,  through  the 
dying  out  of  the  larvae,  striking  reduction  in  their  numbers,  the  rate  of 
reduction  increasing  with  the  passage  of  days. 

Position  of  Larvae  in  the  SoiL  Infective  hookworm  larvae  un- 
der the  most  favorable  conditions  of  moisture  and  temperature  were  found 
to  remain  on  or  near  the  surface  of  the  soil.  They  crept  up  pieces  of 
wood,  decaying  vegetation,  and  other  objects  only  as  far  as  a  film  of 
moisture  extended.  They  were  not  found  within  drops  of  water  collected 
in  the  axils  of  leaves  or  green  plants,  nor  upon  the  leaves  themselves. 
At  the  centers  of  soil  infestation  they  were  found  on  the  leaves  Qr  twigs 

12 


l80      THE  ROCKEFELLER  FOUNDATION 

when  the  latter  were  moist.    When  the  leaves  or  twigs  were  dry,  the 
larvae  retreated  to  the  underlying  soil. 

GREATER  SPEED  AND  ECONOMY  IN  FIELD  OPERATIONS 

The  demonstration  by  Cort  and  his  associates  that  the  life  of  hookworm 
larvae  in  the  soil  is  much  shorter  than  had  been  commonly  supposed;  that 
the  larvae  do  not  migrate;  and  the  earlier  demonstration  by  Smillie  that 
hookworms  are  slowly  acquired  and  slowly  lost,  find  complete  confirma- 
tion in  the  results  of  the  1921  resurveys  of  Governor's  Island  and  Jaca- 
repagua,  Brazil  (see  pages  127  to  129).  Not  only  do  these  findings  abun- 
dantly confirm  the  fundamental  soundness  of  the  working  methods  that 
have  been  employed  to  effect  the  control  of  hookworm  disease,  but  they 
indicate  the  lines  to  be  pursued  in  future  efforts  to  secure  greater  speed, 
economy,  and  efficiency  in  field  operations.  With  the  data  now  at  hand 
it  is  possible  to  formulate  a  simplified  plan  of  procedure  based,  not  on 
removing  the  last  hookworm  from  every  infected  individual,  but  on  keep- 
ing reduced  to  a  point  at  which  they  do  no  serious  harm  to  the  indi- 
vidual or  to  the  community,  the  number  of  worms  harbored.  A  paper 
recently  published  by  Dr.  Smillie  gives  the  details  of  a  method  he  has 
evolved  to  meet  this  end.^ 

Plan  of  Control  for  Heavily  Infected  Areas.  In  communities 
where  almost  all  the  people  are  soil  workers — poor,  ignorant,  barefoot, 
spending  ten  or  twelve  hours  daily  in  the  fields,  and  subjected  to  all  the 
factors  that  tend  toward  heavy  infection — Dr.  Smillie  recommends  a 
preliminary  treatment  campaign  in  which  three  treatments  of  a  standard 
remedy  would  be  given  to  all  workers  in  the  soil.  Simultaneously  the 
attempt  would  be  made  to  secure  the  installation  of  latrines  at  not  less 
than  three  fourths  of  the  houses.  After  this  proportion  of  the  homes  had 
sanitary  latrines  a  second  treatment  campaign  would  follow.  In  the 
second  campaign  every  positive  case  would  receive  only  one  treatment, 
and  special  effort  would  be  made  to  treat  all  who  work  in  the  soil.  Fol- 
lowing this,  a  small  staff  would  be  stationed  permanently  in  the  commu- 
nity to  secure  the  continued  construction  and  maintenance  of  latrines,  to 
treat  newcomers,  and  to  serve  as  the  basis  for  a  future  rural  health  unit. 

Plan  for  Lightly  Infected  Areas.  In  communities  whose  in- 
habitants generally  are  in  better  circumstances,  accustomed  to  a  better 
mode  of  living,  and  less  severely  infected,  he  recommends  treating  twice 
all  positive  cases  except  soil  workers,  whom  he  would  treat  three  times, 
and  at  the  same  time  inaugurating  a  campaign  of  latrine  construction. 
Upon  completion  of  treatment  a  small  staff,  who  would  remain  to  con- 
tinue the  work  of  latrine  construction  and  to  treat  newcomers,  would 
devote  certain  days  of  each  week  to  general  dispensary  work,  when  they 
would  treat  any  hookworm  infected  persons  who  came  to  the  clinic. 
Here,  again,  the  small  unit  would  serve  as  the  basis  for  extending  perma- 

1  The  Results  of  Hookworm  Disease  Prophylaxis  in  Brazil,  by  Wilson  G.  Smillie. 
The  American  Journal  of  Hygiene,  January,  1922,  v.  2,  No.  i,  pp.  91-94.  Same  re- 
printed. 


INTERNATIONAL  HEALTH  BOARD 


iSi 


nent  rural  sanitary  activities  throughout  the  community.  While  hook- 
worm infection  would  not  be  eradicated  by  either  of  these  plans, 
hookworm  disease  would  be  adequately  controlled  if  latrines  were  con- 
structed and  faithfully  maintained  and  used. 

Mass  Treatment  in  Absence  of  Latrine  Provision.  In  com- 
munities whose  inhabitants  suffer  with  severe  hookworm  disease  and  who 
either  cannot  or  will  not  build  and  use  latrines,  treatment  is  the  only 
method  of  attack  that  can  be  used.  The  Brazilian  experience  shows  that 
an  individual  who  receives  two  standard  treatments  and  is  thus  freed  of 
practically  all  his  hookworms,  but  who  reverts  to  the  conditions  of  living 
which  produced  his  first  infection,  does  not  usually  regain  a  large  comple- 
ment of  worms  until  at  least  three  years  have  elapsed.  Under  such 
circumstances  it  is  therefore  safe  to  follow  the  plan  of  giving  all  individ- 
uals a  standard  treatment  once  a  year. 


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Fig.  S3._ — Number  of  persons  examined  and  treated  in  world-wide  cam- 
paign against  hookworm  disease,  1910-1921,  inclusive,  by  main  geograph- 
ical divisions  (for  details,  see  Table  1,  page  218.) 


EFFECT  OF  SALT  ON  VIABILITY  OF  HOOKWORM  EGGS 
AND  LARVAE 

A  limited  study  of  the  effect  of  salt  on  the  viability  of  hookworm  eggs 
and  larvae,  carried  out  during  1921  by  Dr.  Fred  C.  Caldwell,  director  of 
hookworm  control  in  Panama,  showed  that  for  all  practical  purposes  sea 
water  prevents  the  development  of  larvae.  Particularly  favorable  con- 
ditions for  the  study  were  afforded  by  the  habits  of  the  San  Bias  Indians, 
who  live  on  227  islands  stretched  along  130  miles  of  coast  and  have  the 
time-honored,  inviolate  custom  of  defecating  in  the  sea.  Non-Indian 
residents,  however,  frequently  pollute  the  soil.     In  a  number  of  localities 


I82 


THE  ROCKEFELLER  FOUNDATION 


on  three  islands  having  the  same  climatic  conditions,  the  average  rate  of 
infection  among  595  Indians  examined  was  only  4.7  per  cent,  as  compared 
with  the  rate  of  62.9  per  cent  among  thirty-five  non-Indian  residents. 

In  the  Spanish  village  of  Puerto  Obaldia  on  the  San  Bias  coast,  where 
soil  pollution  was  general,  every  person  examined  was  found  infected.  A 
large  proportion  of  the  non-Indian  population  of  all  three  of  the  islands 
had  lived  for  considerable  periods  in  the  city  of  Panama,  a  fact  that  is 
doubtless  responsible  for  the  rate  of  infection  being  lower  among  them 
than  it  would  have  been  if  they  had  spent  their  whole  lives  on  the  islands. 
All  the  infected  Indians  had  either  spent  extended  periods  on  the  mainland 
or  had  lived  in  close  association  with  Jamaicans  or  Colombians  while 
engaged  in  the  gathering  of  rubber. 


80% 


60% 


40% 


^  FIRST  INSPECTION 
^SECOND  INSPECTION 

A       NO  LATRINES 

B       INSANITARY  LATRINES 

C       SANITARY  LATRINES 


m 

7/ 


WEL 


SOUTHERN  STATES 


WEST  INDIES 


CENTRAL  AMERICA 


SOUTH  AMERICA 


THE  EAST 


Fig.  54. — Sanitary  conditions  on  first  and  last  inspections  compared 
for  the  five  main  geographical  divisions  of  the  world-wide  campaign 
against  hookworm  disease,  1910-1921.  In  all  regions  extensive  sanitary 
improvement  has  gone  hand-in-hand  with  treatment 


APPARATUS  FOR  RECOVERING  HOOKWORM  LARVAE 
FROM  THE  SOIL 


The  staff  engaged  in  the  investigations  in  Trinidad  used  with  much 
success,  in  every  phase  of  their  work,  a  modification  of  the  apparatus  in- 
vented by  Baermann  for  recovering  larvae  from  the  soil.  It  permitted 
determination  to  be  made  of  the  exact  sources  of  infection  through  exami- 
nation of  large  numbers  of  soil  samples  from  various  parts  of  areas  in 
which  hookworm  disease  was  prevalent;  it  enabled  the  staff  to  follow 


INTERNATIONAL    HEALTH    BOARD  1 83 

closely  the  reduction  of  soil  infectivity  that  resulted  from  the  elimination 
of  soil  pollution;  and  it  made  possible  not  only  a  careful  study  of  the  con 
ditions  under  which  the  eggs  develop,  but  also  of  the  extent  of  migration 
of  the  larvae,  the  rate  of  unsheathing,  and  the  length  of  larval  life  in  differ- 
ent kinds  of  soil. 

The  apparatus  consists  of  a  glass  funnel  almost  filled  with  water  and 
with  the  outlet  closed  by  a  clamped  piece  of  rubber  tubing.  The  soil 
sample  is  placed  in  a  sieve  so  fitted  into  the  funnel  that  the  level  of  the 
water  is  above  the  lower  surface  of  the  soil,  thus  bringing  the  soil  sample 
into  contact  with  water  of  a  considerably  higher  temperature  than  that 
of  the  soil.  Under  these  conditions  a  large  proportion  of  the  nematodes 
pass  from  the  sample  into  the  water,  where  they  can  be  collected  and 
counted. 

For  examining  soil  samples  of  half  a  pint  or  more,  large  glass  funnels 
eight  inches  in  diameter,  and  specially  prepared  brass  sieves  seven  inches 
in  diameter,  three  inches  deep,  and  with  a  one  millimeter  mesh,  were  used. 
To  prevent  small  particles  of  soil  sifting  through  into  the  funnels  the  sieves 
were  lined  with  one  or  two  thicknesses  of  cloth.  It  is  possible  to  substitute 
for  the  sieve  a  piece  of  wire  screen  covered  with  cloth,  of  such  a  size  that 
it  can  be  fitted  down  into  the  funnel.  The  sieves  have  the  advantage, 
however,  of  being  more  easily  handled  in  changing  samples  of  soil. 


Ill 

DIAGNOSIS  OF  HOOKWORM  DISEASE 
WILLIS  SALT-FLOTATION  TECHNIQUE 

The  Willis  salt-flotation  technique  of  stool  examination  found  added 
favor  in  the  work  of  the  year.  It  is  proving  particularly  valuable  for  de- 
tecting light  infections  usually  missed  by  the  less  refined  plain  smear  and 
centrifuge  processes.  In  Salvador,  for  example,  it  increased  by  10  to 
15  per  cent  the  number  of  specimens  found  positive  with  the  aid  of  the 
centrifuge.  In  Ceylon  449  additional  positives  were  found  in  a  group  of 
1,569  specimens — an  increase  in  efficiency  of  28.6  per  cent. 

The  process  calls  for  adding  to  the  feces  a  saturated  solution  of  coarse 
table  salt  drop  by  drop  until  the  container  in  which  the  specimen  is  re- 
ceived is  filled  to  the  brim.  The  mixture  is  thoroughly  stirred  and  al- 
lowed to  stand  for  a  few  minutes  to  permit  the  ova  to  rise.  A  clean 
polished  slide  is  then  placed  on  the  container  in  contact  with  the  surface 
of  the  fluid.  In  a  short  time  the  ova  adhere  to  the  slide,  which  is  re- 
moved and  examined  with  the  microscope.  The  method  is  so  simple, 
efficient,  and  economical  that  it  is  rapidly  coming  into  use  in  all  countries. 
Tests  in  Queensland  showed  that  as  compared  with  the  brine  flotation 
method  the  Willis  technique  had  the  advantage  of  being  quicker;  of  re- 
quiring less  apparatus,  no  steel  wool  and  no  wire  loops  being  needed;  of 
using  less  salt  solution;  and  of  permitting  the  discarding  of  the  tins  after 
use  and  so  offering  no  possibility  of  ova  being  carried  from  one  tin  to 
another. 

To  facilitate  examination  by  the  Willis  method  Dr.  Molloy,  in  Nica- 
ragua, has  improvised  a  special  board  which  has  proved  effective  in  field 
work.  The  board — the  end  of  a  box  in  which  gasoline  is  shipped — meas- 
ures 13 1  by  9|  inches,  and  is  covered  on  one  side  with  a  piece  of  tin  to 
facilitate  washing.  To  this  board  are  nailed,  in  two  rows,  the  tops  of 
ten  containers.  The  specimen  containers  are  placed  in  these  tops  before 
the  salt  solution  is  added.  The  board  is  of  a  convenient  size  to  handle 
and  is  easily  cleaned. 

LANE  LEVITATION  METHOD 

Colonel  Sir  Clayton  Lane,  who  has  been  at  work  for  several  yeara 
seeking  to  develop  a  technique  of  stool  examination  that  will  combine 
the  utmost  simplicity  with  the  greatest  refinement,  recommends  a  levi- 
tation  process  and  stresses  the  advisability  of  using  chemicals  to  preserve 
the  stools  and  so  permit  their  examination  under  more  favorable  circum- 
stances than  are  usually  found  in  the  field.  The  fact  that  levitation  may 
be  applied  as  successfully  in  preserved  as  in  fresh  stools,  if  certain  disin- 

184 


INTERNATIONAL  HEALTH   BOARD  1 85 

fectants  are  used,  offers  the  hope  that  it  may  prove  practicable  to  effect 
further  economy  and  efficiency  by  dissociating  diagnosis,  in  time  and 
place,  from  the  other  phases  of  hookworm  work. 

Dr.  Lane  finds  that  the  process  of  levitation  when  properly  carried  out 
collects  in  a  condition  of  full  visibility  an  average  of  ten  times  as  many 
eggs  as  can  be  secured  by  other  methods  of  slide  preparation.  In  Bengal, 
for  instance,  he  added  by  levitation  about  10  per  cent  to  the  infection 
figures  obtained  from  strained  and  centrifuged  films;  and  Dr.  Mhaskar, 
testing  the  results  of  examination  by  searching  the  stools  for  hookworms 
after  a  vermifuge  had  been  given,  found  that  levitation  had  disclosed  7 
per  cent  more  positive  cases  than  had  been  yielded  by  ordinary  film 
examination.  Dr.  Lane  is  continuing  his  studies  with  the  aid  of  a  small 
subvention  from  the  Board,  and  proposes  to  establish,  by  actual  counts  of 
eggs  in  fixed  quantities  of  stool,  what  proportion  of  the  eggs  are  lost  and 
what  proportion  are  collected  in  a  condition  of  full,  uncamouflaged  visi- 
bility, in  examinations  by  the  plain  smear,  the  centrifuge,  the  salt  flota- 
tion, and  the  levitation  techniques.  In  each  case  comparison  will  be 
made  of  the  figures  for  stools  treated  and  stools  untreated  by  chemical 
preservatives. 

ESTIMATING  SEVERITY  BY  COUNTING  EGGS  IN  FECES 

Dr.  W.  G.  Smillie  conducted  in  Brazil  during  1921  a  test  in  which  he 
sought  to  ascertain  the  possibility  of  estimating  the  severity  of  infection 
by  counting  the  ova  in  the  microscopic  field.  One  hundred  thirty-five 
cases  harboring  an  average  of  thirty-two  worms  each,  forty  of  which  had 
been  found  negative  with  the  microscope,  were  included  in  the  test. 
The  centrifuge  method  of  examination  was  used,  and  the  positive  cases 
were  classified  into  five  groups  in  accordance  with  the  number  of  ova 
found  in  the  stools.  The  cases  were  later  treated  and  all  their  worms 
expelled. 

So  far  as  general  averages  were  concerned  there  was  a  definite  relation- 
ship between  the  number  of  ova  in  the  stools  and  the  number  of  worms  in 
the  intestines,  but  in  individual  cases  the  clue  afforded  by  a  single  exam- 
ination of  the  stool  was  very  unreliable.  One  individual  having  very 
abundant  ova  harbored  only  twenty-three  hookworms;  while  others  hav- 
ing so  few  ova  that  they  were  found  only  after  long  and  careful  search, 
harbored  from  150  to  200  hookworms. 

DIFFERENTIATION    OF    HOOKWORM    AND    STRONGY- 
LOID  LARVAE 

In  the  routine  examination  of  feces  in  field  laboratories  it  is  difficult 
to  distinguish  hookworm  from  Strongyloid  larvae.  Dr.  Smillie  has 
evolved  a  simple  process  for  identifying  the  larvae,  based  on  the  marked 
differentiation  that  takes  place  as  they  mature.  The  technique  results 
in  many  specimens  being  found  to  contain  Strongyloides  that  are  unrecog- 
nized by  routine  microscopic  examination. 


1 86      THE  ROCKEFELLER  FOUNDATION 

At  the  end  of  the  day's  work  specimens  containing  the  larvae  to  be 
identified  are  prepared  in  a  Petri  dish  of  standard  size.  In  the  center  of 
the  dish  a  circle  from  five  to  seven  centimeters  in  diameter  is  drawn  with 
a  wax  pencil  or  with  cocoa  butter.  Within  this  circle  are  placed  from  one 
to  two  grams  of  feces  and  from  one  to  two  mils  of  water.  The  dishes  are 
covered  and  allowed  to  stand  at  a  temperature  of  from  75"  to  90°  Fahren- 
heit. The  cultures  may  be  observed  on  the  following  morning — fourteen 
hours  after  preparation, — and  again  on  the  second  morning — forty  hours 
after  the  culture  was  begun.  The  top  is  removed  from  the  Petri  dish 
and  an  ordinary  hand  lens  is  used  in  searching  for  larvae  in  the  water  sur- 
rounding the  feces.  During  the  interval  of  fourteen  hours  the  larvae 
leave  the  feces  for  the  surrounding  water  and  swim  freely  about  in  large 
numbers. 

The  different  habits  and  sizes  of  the  two  larvae  render  identification 
easy.  The  Strongyloides  occur  in  two  forms:  the  first  as  free  living  adult 
males  and  females,  which  usually  appear  near  the  margin  of  the  feces 
and  are  of  a  size  to  be  readily  visible  to  the  naked  eye;  and  the 
second  as  filariform  Strongyloid  larvae  found  at  the  very  periphery  of 
the  water,  usually  with  their  bodies  at  a  right  angle  to  the  circle,  and  in 
active,  even  frantic,  motion.  Hookworm  larvae  differ  from  the  free 
living  Strongyloides  in  that  they  are  many  times  smaller  and  are  usually 
found  at  or  near  the  fecal  margins.  They  are  sluggish  in  motion  and  thus 
offer  a  marked  contrast  to  the  active  filariform  Strongyloid  larvae. 


r 


IV 

MALARIA  CONTROL 

ANTI-MOSOUITO   MEASURES:  SOUTHERN  STATES 

Malaria  control  by  anti-mosquito  measures  made  marked  progress  in 
the  Southern  States  during  the  year.  Despite  unfavorable  financial  and 
climatic  conditions  a  total  area  of  225  square  miles  was  controlled  and  a 
total  population  of  228,740  persons  protected.  Through  joint  co-opera- 
tion between  the  town  and  county  authorities,  the  state  boards  of  health, 
the  United  States  Public  Health  Service,  and  the  International  Health 
Board,  new  demonstrations  were  conducted  in  twenty-six  towns  in  the 
states  of  Alabama,  Arkansas,  Georgia,  Louisiana,  Mississippi,  North 
Carolina,  South  Carolina,  Tennessee,  and  Texas;  and  in  thirty-five  other 
towns  in  these  states  and  in  Virginia  supervision  was  given  to  the  main- 
tenance of  control  established  in  previous  years.  A  considerable  number 
of  towns  also  conducted  control  measures  on  their  own  initiative  and 
without  outside  assistance,  a  number  of  transportation  and  industrial  cor- 
porations interested  themselves  in  anti-mosquito  activities,  and  from  the 
towns  the  work  began  to  spread  to  rural  communities. 

Measures  Employed.  In  the  work  of  control,  effort  centers  on 
the  elimination  of  the  breeding  places  of  malaria  mosquitoes.  The 
measures  employed  consist  of  simple  drainage,  filling  borrow  pits  and  shal- 
low pools,  channeling  streams,  clearing  the  margins  of  streams  and  ponds, 
removing  obstructions,  letting  in  the  sunlight,  oiling,  and  enlisting  the 
services  of  the  top  minnow  {Gambusia  afinis)  to  keep  down  breeding. 
It  is  necessary  also  to  protect  unscreened  or  unsatisfactorily  screened 
wells  and  cisterns  and  to  remove  or  cover  old  tin  cans  and  similar  artificial 
containers. 

In  all  towns  in  wjbich  work  is  conducted  preliminary  surveys  are  made 
to  determine  whether  efi"ective  malaria  control  can  be  secured  at  reason- 
able cost.  Whenever  possible  the  surveys  are  made  late  in  the  summer 
or  in  the  autumn  of  the  year  preceding  the  beginning  of  control  effort. 
The  drainage  operations  are  usually  so  planned  as  to  be  practically  com- 
pleted before  the  mosquito  season  opens. 

The  measures  employed,  while  practically  eliminating  the  malaria 
mosquito,  do  not  guarantee  freedom  from  the  mosquito  as  a  pest.  A  sig- 
nificant decrease  in  the  numbers  of  all  mosquitoes — Culex  as  well  as 
Anopheles — results,  but  it  is  much  more  difficult  and  expensive  to  obtain 
freedom  from  all  mosquitoes  than  from  Anopheles  alone.  To  obtain 
complete  mosquito  control  careful  inspection  of  backyards  and  surround- 
ing premises  is  required. 

Results  and  Costs.  ^  Figures  21  and  22  (pages  113  and  114)  exhibit 
typical  results  accomplished.     The  reduction  in  malaria  on  the  basis  of 

*  All  cost  figures  given  in  this  paragraph  exclude  the  expense  of  general  supervision. 

187 


1 88      THE  ROCKEFELLER  FOUNDATION 

physicians'  calls  is  in  the  case  of  some  towns  as  high  as  90  per  cent. 
Figures  showing  the  reduction  effected  are  not  available  for  all  towns, 
however,  as  information  concerning  malaria  incidence  is  seldom  recorded 
for  the  years  that  precede  the  control  program. 

Several  towns  reported  that  the  control  operations  resulted  in  malaria 
being  completely  eliminated.  Physicians  were  practically  unanimous  in 
reporting  a  marked  reduction  in  the  number  of  their  visits  for  malaria, 
and  pharmacists  stated  that  there  had  been  a  noticeable  diminution  in 
the  demand  for  chill  tonics  and  similar  proprietary  "  remedies  "  for  malaria. 

In  the  new  towns  the  cost  of  original  installation  during  1921  ranged 
from  3225  for  the  town  with  the  lowest  cost  to  36,234  for  that  with  the 
highest,  the  total  for  the  twenty-six  amounting  to  367,411.  Inasmuch 
as  a  total  population  of  67,063  was  protected,  distributed  in  towns 
varying  in  size  from  268  to  13,088,  the  cost  per  capita  was  31.01.  In 
the  other  thirty-five  towns  the  maintenance  measures  protected  a  total 
population  of  161,677  at  an  average  cost  per  capita  of  only  twenty-five 
cents. 

Data  submitted  by  thirteen  of  the  twenty-six  installation  towns  indi- 
cate that  the  average  first  year's  cost  of  each  main  feature  of  the  work 
was  as  follows:  ditching  3345  per  mile,  clearing  streams  395  per  mile, 
and  oiling  33  per  mile.  The  average  cost  of  maintenance  was  316  per 
mile.  Premises  were  inspected  for  mosquito  breeding  at  an  average  cost 
of  six  cents.  All  of  these  costs,  of  course,  are  subject  to  wide  variation 
depending  upon  conditions  to  be  met.  Nevertheless,  it  is  felt  that  the 
averages  are  fairly  representative.  In  some  towns  natural  conditions 
made  possible  control  at  trifling  cost.  Thus,  in  Bullard,  Texas,  control 
was  secured  for  only  366.83,  of  which  311-83  was  spent  for  oil  and  355 
for  the  labor  of  applying  it. 

The  effectiveness  of  the  control  program  is  well  illustrated  by  statistics 
for  the  town  of  Lake  Charles,  Louisiana.  This  town,  with  its  popula- 
tion of  13,088,  was  embraced  within  the  extra-cantonment  zone  in  which 
anti-mosquito  measures  were  carried  out  by  Government  during  1917. 
For  that  year  the  estimated  calls  for  malaria  numbered  250.  The  next 
year,  following  the  installation  of  control  measures,  the  calls  dropped  to 
eight.  Upon  the  close  of  the  war  control  effort  in  the  town  and  vicinity 
was  permitted  to  lapse,  with  the  result  that  the  cases  of  malaria  rose  to 
500  for  the  year  1920.  In  1921,  following  the  renewal  of  control  effort 
in  April  of  that  year,  the  total  number  of  cases  was  only  fifty. 

Economic  Value  of  Work.  Complete  data  are  not  available  to 
show  the  economic  loss  that  results  from  malaria,  and  estimates  are  in 
most  cases  difficult  to  make.  Nevertheless,  certain  facts  and  figures 
collected  during  1921  are  at  hand  to  indicate  the  saving  in  dollars  and 
cents  effected  by  the  application  of  control  measures. 

Thus,  the  town  of  Lake  Charles,  Louisiana,  sustained  during  the  year 
1920  losses  from  malaria  estimated  at  326,000.  During  1921  control 
measures,  which  practically  stamped  out  malaria  and  eliminated  this  loss, 
were  applied  at  a  cost  of  only  34,965,  representing  a  saving  to  the  town 
in  its  malaria  bill  of  321,035,  or  81  per  cent.    Again,  Mr.  George  L.  Grogan, 


Fig.  55. — Ditch  along  railroad  embankment,  before  and 
after  draining,  Demopolis,  Alabama.  Minor  drainage 
operations  constitute  the  chief  feature  of  anti-mosquito 
measures  as  conducted  in  the  Southern  States 


1 

— s: 

^■II 

m 

'  m 

r^^ 

I^^H 

illHH 

■    ■    '-""^"t^i^^S^ 

p^^s^b^hf 

f 

I 

.,.  1  ij 

mm^ 
^  ■/-"■,.' 

% 

^^1 

^^'^    ^.^.... ..::.... 

Fig.  56. — "V  "-shaped  ditch,  a  part  of  the  drainage  sys- 
tem installed  to  control  malaria  in  and  near  La  Puebla- 
Rivas,  Nicaragua 


Fig.  57. — Anti-malaria,  impounding  water  experiment  at 
Mound,  Louisiana.  View  across  bayou,  700  yards  above 
dam  site,  before  clearing 


Fig.  58. — Same  as  Fig.  57,  showing  bayou  filled  with 
water 


INTERNATIONAL  HEALTH   BOARD  I9I 

manager  of  the  Grogan  Lumber  Company  at  Gladstell,  Texas,  states 
that  the  installation  of  control  measures  during  1921  cost  the  town  a  total 
of  35,036  and  protected  500  people.  In  this  instance  the  first  year  of 
control  cut  the  company's  malaria  bill  in  half. 

Public  Appreciation.  The  work  is  meeting  with  high  favor  in  all 
the  states,  as  is  evidenced  by  the  fact  that  in  practically  all  the  towns 
where  it  has  been  begun  there  is  almost  no  opposition  to  its  continuation.^ 
Many  of  the  towns  in  which  demonstrations  are  made  continue  the  drain- 
age work  during  the  winter  months  and  in  the  spring  have  the  ditching  in 
good  order  for  early  work  to  prevent  mosquito  breeding. 

The  town  of  Crossett,  Arkansas,  continued  control  measures  during 
1921  for  the  sixth  consecutive  year  at  a  cost  of  35,349  for  the  year;  the 
town  of  Hamburg,  Arkansas,  completed  its  fifth,  and  the  towns  of  Lake 
Village  and  Dermott,  Arkansas,  their  fourth,  successful  year  of  malaria 
control  (Figs.  21  and  22,  pages  113  and  114,  exhibit  results  accomplished). 
In  all  these  towns  the  bulk  of  the  citizens  heartily  endorse  the  work  and 
there  is  every  indication  that  it  will  henceforth  be  carried  on  as  a  regular 
municipal  function. 

Consolidation  and  Extension  of  Service.  The  work  of  the  year 
has  been  characterized  by  a  growing  tendency  to  center  control  measures 
in  the  county  health  departments,  and  to  arrange  through  them  not  only 
for  the  initial  installation  but  for  subsequent  supervision  and  maintenance. 
The  state  boards  of  health  are  also  taking  active  interest  in  the  work, 
and  many  of  them  are  securing  their  own  malaria  control  personnel. 
During  the  year  the  Board  assisted  six  of  these  states — Alabama,  Arkan- 
sas, Mississippi,  Missouri,  South  Carolina,  and  Virginia — in  providing 
supervisors  to  assume  direction  of  comprehensive  plans  for  the  control 
of  malaria  within  their  borders.  The  state  boards  of  health  have  made 
creditable  progress  in  securing  legislative  appropriations  for  developing 
and  aiding  in  measures  for  the  control  of  malaria.  It  is  estimated  that 
six  states  expended  at  least  350,000  in  this  way  during  1921.  Future 
plans  contemplate  the  expenditure  of  much  larger  sums  in  this  work. 


COUNTY- WIDE  ANTI-MOSQUITO   MEASURES 

The  effectiveness  of  county-wide  malaria  control  operations  under  the 
direction  of  a  full-time  county  health  officer  was  demonstrated  during 
the  past  year  in  several  Alabama  counties.  The  effort  grew  out  of  the 
work  conducted  during  1920  in  several  towns  of  the  state,  which  awakened 
interest  in  malaria  control  and  suggested  to  the  State  Board  the  idea  of 
attempting  to  carry  out  similar  measures  in  both  towns  and  rural  districts 


»  Following  the  original  survey  and  before  control  effort  is  inaugurated  the  towns 
agree  to  defray  certain  items  of  expense  associated  with  the  work,  as  well  as  to  set 
aside  in  future  years  the  sums  necessary  for  its  maintenance.  The  agreement  en- 
tered into  with  the  towns  contains  careful  estimates  of  original  installation  as  well 
as  maintenance  costs.  Persons  who  may  be  interested  in  the  particulars  of  this 
phase  of  the  work  will  be  furnished  a  sample  copy  of  the  agreement  upon  application 
to  the  International  Health  Board,  61  Broadway,  New  York  City. 


192      THE  ROCKEFELLER  FOUNDATION 

through  the  county  health  departments.  A  malaria  control  engineer 
was  added  to  the  staff  of  the  State  Board,  to  co-operate  with  the  county- 
health  officers,  and  Calhoun,  Talladega,  Sumter,  Morgan,  and  Tusca- 
loosa counties  were  selected  for  the  work.  From  the  inception  education 
and  publicity  were  stressed. 

Extent  of  Control  Effort  Undertaken.  Active  operations  were 
begun  April  1,  192 L  By  the  end  of  April  control  effort  was  going  for- 
ward in  nineteen  centers  of  population.  Gradually  other  towns,  and 
later  the  inhabitants  of  certain  rural  areas,  took  it  up,  until  by  the  first 
of  September  it  was  under  way  in  thirty-two  towns  and  in  fourteen  rural 
districts.  In  some  towns  the  regular  city  employes  devoted  to  the  work 
such  time  as  was  needed;  in  others  the  town  marshal,  assisted  by  prison- 
ers, attended  to  it;  in  others  still  the  towns  paid  nominal  fees  to  some  of 
their  citizens.  During  the  progress  of  operations  in  the  five  counties  a 
total  of  108  miles  of  ditches  were  dug,  1,298  miles  of  waters  were  oiled, 
and  86  miles  of  vegetation  and  other  obstructions  were  cleared  away  from 
the  banks  of  streams,  ponds,  and  similar  bodies  of  water.  In  addition 
136  separate  water  deposits  were  stocked  with  the  larvae-consuming 
top  minnow,  for  the  free  distribution  of  which  hatcheries  were  established 
at  convenient  locations  in  several  of  the  counties. 

Results  and  Cost.  In  the  rural  districts  of  all  the  counties  many 
streams,  lakes,  and  ponds  were  stocked  with  fish  and  many  miles  of  ditches 
were  dug.  In  one  county  in  particular,  where  practically  the  sole  source 
of  Anopheles  mosquitoes  was  stock  ponds  and  small  fish  ponds,  hundreds 
of  these  were  stocked  with  Gambusia  or  were  so  cleaned  by  their  owners 
that  effective  fish  control  was  obtained.  As  a  result  a  tremendous  area 
was  practically  freed  of  Anopheles  mosquitoes.  The  population  protected 
in  the  several  counties  was  92,000,  the  total  sum  expended  33,108.11, 
and  the  cost  per  capita  thirty-four  cents. 

ANTI-MOSOUITO   MEASURES  UNDER  TROPICAL 
CONDITIONS 

Efforts  to  adapt  to  tropical  conditions  the  anti-mosquito  measures 
whose  value  has  been  so  convincingly  demonstrated  in  the  Southern 
States  were  continued  in  Porto  Rico  and  Nicaragua  during  1921.  In 
both  countries  control  is  being  sought  by  the  use  of  top  minnows,  supple- 
mented in  Nicaragua  by  drainage  and  in  Porto  Rico  by  drainage  and  oil- 
ing. The  complete  results  of  the  Porto  Rican  experiment  are  not  yet 
known.  The  data  at  hand  indicate  that  under  tropical  agricultural 
conditions  in  Porto  Rico  malaria  cannot  be  controlled  unless  Anopheles 
breeding  is  prevented  for  a  distance  of  at  least  1/^  miles  from  the  nearest 
house. 

Demonstration  in  La  Puebla-Rivas,  Nicaragua.  During 
March  and  April,  1921,  surveys  were  made  in  two  towns  of  Nicaragua — 
Buenos  Aires  and  La  Puebla-Rivas — to  determine  the  feasibility  of  under- 
taking malaria  control  by  anti-mosquito  measures.     The  surveys  resulted 


INTERNATIONAL  HEALTH   BOARD  1 93 

in  the  recommendation  that  experimental  effort  be  undertaken  in  an  area 
embracing  approximately  three  square  miles,  forming  part  of  the  town 
of  Rivas  and  the  adjoining  semi-rural  district,  really  a  part  of  the  town, 
known  as  La  Puebla.  The  work  begun  here  in  June  has  shown  conclu- 
sively that  anti-mosquito  measures  are  applicable  for  the  control  of  malaria 
in  tropical  towns,  certainly  under  the  conditions  that  exist  in  the  towns 
of  Nicaragua.  The  undertaking  has  awakened  much  interest  in  neighbor- 
ing communities,  a  number  of  which  are  requesting  assistance  along 
similar  lines. 

Results  and  Costs  in  La  Puebla-Rivas.  No  data  are  available 
for  physicians'  calls  in  earlier  years.  However,  43.6  per  cent  of  the  total 
population  of  1,416  gave  a  history  of  attacks  of  malaria  during  the  pre- 
ceding twelve  months.  Examination  of  the  blood  of  200  persons,  made 
for  the  purpose  of  checking  the  history  index,  yielded  139  positive  results 
among  152  persons  who  gave  positive  histories,  and  indicated  the  histo- 
ries to  be  approximately  90  per  cent  accurate. 

During  the  period  of  control  effort  (June  to  December,  1921),  which 
includes  the  period  of  highest  malaria  incidence  (August  to  December), 
27.7  per  cent  of  the  inhabitants  had  febrile  attacks  resembling  malaria, 
indicating  a  diminution  in  the  malaria  rate  of  36.5  per  cent  as  compared 
with  the  incidence  for  the  preceding  year.  A  parasite  index  of  525  chil- 
dren, taken  in  August,  1921,  and  to  be  repeated  in  January  and  February 
and  again  in  August  of  1922,  will  give  a  truer  estimate  of  results.  There 
can  be  little  doubt,  however,  that  the  degree  of  protection  afforded  was 
much  higher  than  is  suggested  by  the  estimated  reduction  of  36.5  per 
cent,  inasmuch  as  relapses  unquestionably  played  an  important  part  in 
raising  the  1921  figures. 

Excluding  the  expenditures  for  general  supervision,  the  work  was  con- 
ducted at  a  per  capita  cost  of  seventy-four  cents  for  the  seven  months  it 
was  in  progress,  or  at  an  average  rate  of  about  one  dollar  for  the  year. 
This  cost  of  original  installation  is  slightly  below  the  average  cost  of 
similar  work  in  the  Southern  States.  There  is,  moreover,  every  prospect 
that  under  Nicaraguan  conditions  the  cost  of  maintenance  will  be  con- 
siderably lower. 

CONTROL  BY   STERILIZATION  OF   CARRIERS 

The  Mississippi  delta  is  one  of  the  regions  In  which  the  control  of  mos- 
quito breeding  is  not  economically  feasible.  In  this  region,  therefore, 
experimental  work  In  the  control  of  malaria  has  been  concerned  with  the 
sterilization  of  carriers.  The  work  has  been  conducted  under  the  gen- 
eral supervision  of  the  Mississippi  Department  of  Health  and  under  the 
scientific  direction  of  Dr.  C.  C.  Bass,  Professor  of  Experimental  Medicine 
in  Tulane  University.  It  has  been  under  way  since  1916  and  has  dealt 
with  many  thousands  of  people.  In  the  opinion  of  Dr.  Bass  Its  results 
indicate  that  with  sufficient  quinine  available  and  the  people  sincerely 
desirous  of  being  rid  of  the  disease,  malaria  may  he  controlled  by  quinine 
treatment  alone  In  any  area  of  the  world. 


194      THE  ROCKEFELLER  FOUNDATION 

Extent  of  Experimental  Effort.  The  study  was  conducted  during 
1916  and  1917  in  an  area  of  328  square  miles  in  Bolivar  county,  Missis- 
sippi. As  a  check  on  the  results  accomplished  and  while  the  figures  for 
the  Bolivar  county  work  were  being  analyzed,  work  was  also  undertaken 
at  the  state  prison  farms  in  Sunflower  and  Quitman  counties  and  at 
Parchman  Penitentiary  in  Sunflower  county. 

The  total  population  dealt  with  during  the  two  years  was  about  35,000. 
During  1916  the  work  was  conducted  in  an  area  of  225  square  miles  with 
a  population  of  20,040.  A  total  of  37,841  blood  specimens  were  examined 
during  the  year,  and  13,403  quinine  treatments  were  given.  During  1917 
an  additional  area  of  103  square  miles  was  covered  and  a  large  part  of  the 
1916  area  was  investigated  once  or  oftener  to  ascertain  what  effect  the 
quinine  treatment  of  the  preceding  year  had  had  upon  the  incidence  of 
malaria.  A  total  of  45,889  blood  specimens  were  examined  during  this 
year  and  8,774  quinine  treatments  given. 

Method  of  Treatment  Experimentally  Developed.  The  ob- 
servations made  during  this  two-year  period  shed  considerable  light  upon 
many  important  questions  involved  in  malaria  control.  Extensive  tests 
of  diff'erent  salts  and  doses  of  quinine,  carried  on  during  1917  at  the  prison 
farm  in  Sunflower  county — because  more  dependable  observations  could 
be  made  on  convicts  than  on  free  living  people — together  with  experiments 
in  methods  of  treatment  followed  by  resurveys  in  various  other  communi- 
ties during  1917  and  1918,  made  it  possible  to  develop  a  standard  treat- 
ment that  gave  promise  of  effectively  immunizing  the  carriers. 

Thorough  investigations  were  undertaken  to  determine  such  questions 
as  the  total  amount  of  quinine  necessary  to  disinfect  adults  and  children, 
the  form  in  which  the  drug  was  most  effective,  the  size  of  the  daily  dose, 
the  manner  in  which  the  drug  could  be  most  conveniently  and  most 
effectively  administered,  the  length  of  time  over  which  treatment  should 
be  given,  and  the  time  or  times  of  day  at  which  it  should  be  taken.  At- 
tention was  also  devoted  to  the  question  of  whether  or  not  there  are  per- 
sons to  whom,  because  of  a  constitutional  idiosyncrasy,  the  drug  may  not 
be  administered. 

Before  adoption  as  part  of  the  standard  routine  each  particular  phase 
of  the  treatment  was  experimentally  tested  and  checked  from  carefully 
compiled  records.  The  dosage  finally  decided  upon  was  ten  grains  of 
quinine  "sulphate,  with  the  following  proportionate  doses  for  children: 

Age 

Under  i 

1  year 

2  years 
3-4  years 
5-7  years 
8-10  years 

I I- I 4  years 
IS  and  over 

The  medicine  was  to  be  taken  at  bedtime  each  night  for  a  period  of  eight 
weeks.  That  the  ten  grains  daily  dose  was  about  the  smallest  dose  that 
could  be  depended  upon  to  prevent  multiplication  of  the  parasites  w^s 


'^ro^o\ 

riion  of 

Adult  Dose 

0 

.05 

0 

,1 

0, 

.2 

0 

.3 

0 

.4 

0 

.6 

0 

.8 

I 

.0 

se  for  Children 

i  grain 

I  grain 

2  grains 

3  grains 

4  grains 

6  grains 

8  grains 

10  grains 

INTERNATIONAL  HEALTH  BOARD 


I9S 


shown  by  the  fact  that  clinical  symptoms  developed  in  a  few  instances 
among  the  several  thousand  persons  who  were  taking  it.  According  to 
data  collected  the  treatment  disinfected  more  than  90  per  cent  of  the  car* 
riers,  relapses  occurring  in  very  rare  instances.  The  studies  indicated 
that  there  were  few  people  to  whom  it  was  unsafe  to  administer  quinine. 

In  two  communities  prophylactic 
treatment  was  used;  that  is,  smaller 
quantities  of  quinine  were  adminis- 
tered over  a  longer  period  of  time — 
not  in  an  effort  to  cure  or  disinfect, 
but  merely  to  guard  against  acute 
attacks.  The  results  indicated  that 
if  such  treatment  were  continued  dur- 
ing the  transmission  season  for  several 
years,  it  would  effect  a  great  reduction 
in  the  incidence  of  malaria.  How- 
ever, thirty-two  persons  among  the 
1,657  who  took  prophylactic  treatment 
suffered  malaria  attacks  and  had  to 
be  put  upon  curative  treatment. 

Test  of  Treatment  in  Sun- 
flovi^er  County,  1918.  The  next 
step  was  to  test  the  efficacy  of  the 
immunizing  treatment  as  a  control 
measure  in  a  typically  malarious  re- 
gion. Accordingly,  in  1918,  a  demon- 
stration campaign  was  inaugurated  in 
an  area  of  100  square  miles  located  in 
Sunflower  county,  Mississippi.  This 
area  had  a  rural  population  of  8,052, 
with  1,000  additional  persons  residing 
in  the  town  of  Ruleville. 

The  proposed  plan  called  for  public 
meetings  to  advertise  the  scope  and 
purpose  of  the  work,  for  malaria 
surveys,  for  the  furnishing  of  free 
quinine  to  all  persons  who  gave  posi- 
tive histories  or  positive  blood  indices, 
and  for  following  up  the  quinine  treat- 
ment to  see  that  it  was  taken  on  a 

regular  weekly  schedule.    The  work  was  to  advance  and  to  enter  new 
communities  as  rapidly  as  conditions  and  facilities  would  permit. 

Modification  of  Demonstration  Efifort,  1919-1921.  This  first 
demonstration  achieved  a  considerable  degree  of  malaria  control.  For 
the  next  year  it  was  decided  to  discontinue  free  quinine  treatment  and  to 
rely  on  county-wide  publicity  measures  to  stimulate  the  use  of  quinine  in 
sufficient  quantities  for  a  cure.     Practically  nothing  was  done  during  1919 


Fig.  59. — Quinine  treatment 
controls  malaria.  In  an  area  of 
100  square  miles  in  Sunflower 
county,  Mississippi,  only  one 
third  of  the  Infected  persons 
treated  in  1918  suffered  attacks 
the  following  year.  Graph  based 
on  history  index 


196      THE  ROCKEFELLER  FOUNDATION 

in  the  100  square  mile  area  to  hold  what  had  been  gained  in  the  1918 
campaign,  but  the  area  was  resurveyed  in  an  effort  to  obtain  further 
information  about  the  results  of  the  earlier  work.  During  1920  and  1921 
there  was  a  return  to  the  100  square  mile  area  and  an  attempt  to  effect 
a  further  reduction  in  the  incidence  of  malaria  by  persuading  infected 
persons  to  buy  the  quinine  and  take  the  standard  treatments.  Intensive 
resurveys  of  the  area  were  also  carried  on  in  both  these  years. 

To  summarize,  the  work  of  the  four  demonstration  years  was  as  follows: 

1918 — Intensive  work  in  100  square  mile  area. 

1919 — General  publicity  measures  over  entire  county  to  induce  infected 
persons  to  buy  and  take  standard  quinine  treatment. 
No  special  work  in  100  square  mile  area  except  resurveys  to 
determine  results  of  1918  effort. 

1920 — Return  to  100  square  mile  area  to  check  up  results  of  1918  work 
and  to  attempt  further  reduction  in  prevalence.  As  far  as 
possible  the  various  communities  were  taken  up  in  the  same 
order  as  in  1918.  Intensive  resurveys  were  made,  complete 
records  kept,  and  those  who  had  malaria  were  advised  to  buy 
and  take  the  standard  quinine  treatment. 

1921 — Same  kind  of  resurvey  and  follow-up  work  as  in  1920  conducted 
in  100  square  mile  area. 

Result  of  Demonstration  Effort.  In  spite  of  the  fact  that  free 
distribution  of  quinine  was  discontinued  at  the  close  of  1918,  that  the 
majority  of  the  people  in  the  100  square  mile  area  were  not  again  reached 
intensively  until  about  two  years  later,  and  that  quinine  was  not  furnished 
them  gratuitously  even  then,  malaria  was  considerably  less  prevalent  in 
the  area  at  the  close  of  1920  than  it  was  at  the  time  of  the  first  survey. 
Definite  figures  for  the  reduction  accomplished  to  the  end  of  1920  cannot 
be  announced  until  the  returns  for  1921  surveys  have  been  completely 
studied.  However,  the  number  of  cases  of  malaria  per  100,000  residents 
during  1920  was  34.4  per  cent  lower  in  the  100  square  mile  area  than  in 
the  whole  county,  and  the  death  rate  per  100,000  population  was  65.9 
per  cent  lower.  Figures  to  the  end  of  1919  indicate,  moreover,  that  the 
incidence  of  malaria  was  only  13.2  per  cent  among  residents  of  the  100 
square  mile  area  who  had  been  treated  in  1918,  as  compared  with  the  in- 
cidence of  40.2  per  cent  that  obtained  among  these  people  at  the  time  of 
their  first  quininization — a  reduction  of  67.2  per  cent.  In  the  intensive 
work  in  the  100  square  mile  area  there  was  expended  during  1918  the  sum 
of  38,633.44,  during  1920,  33,349.81,  and  during  1921,  33,454.72.  For 
the  respective  years  the  per  capita  costs  were  31-16,  3-38,  and  3-38,  or 
an  average  for  the  three  years  of  3-70.^ 

Distribution  and  Sale  of  Standard  Quinine  Packets.    The 

immunizing  dose  of  quinine  adopted  after  the  experimental  work  in  Boli- 
var and  Sunflower  counties  was  endorsed  by  the  United  States  Public 


>  All  cost  figures  exclude  the  expenditure  for  general  supervision. 


INTERNATIONAL  HEALTH   BOARD  1 97 

Health  Service  in  1918.  In  1919  the  National  Malaria  Committee 
adopted  it  and  recommended  it  to  practicing  physicians  and  to  the  pub- 
lishers of  medical  textbooks.  State  and  county  health  departments  in 
Mississippi  and  other  states  are  now  stimulating  the  distribution  and  sale 
of  handy  packets  containing  the  standard  treatment  at  all  drug  and  cross- 
road stores.  In  the  Southern  States  several  million  doses  have  been 
taken.  Six  hundred  thousand  were  taken  in  one  Georgia  county  alone 
during  the  year  1920.  Among  the  10,000  persons  who  took  the  medicine 
only  twenty-seven  developed  chills  and  fever. 

Determining  the  Malaria  Carriers.^  For  estimating  the  prev- 
alence of  malaria  in  original  surveys  as  well  as  resurveys,  a  combination 
of  history  and  blood  indices  was  used.  In  taking  the  histories  only  those 
persons  were  recorded  as  positive  who  had  had  attacks  within  twelve 
months.  Persons  who  have  not  had  attacks  within  this  period  are  usually 
free  of  the  parasites  and  are  not  malaria  carriers.  In  no  case  was  the  blood 
of  persons  giving  positive  histories  examined  unless  there  was  some 
special  reason  for  so  doing. 

The  blood  of  31,459  persons  was  examined  one  or  more  times  during 
1916  and  1917,  and  malaria  parasites  were  found  in  21.2  per  cent  of  the 
cases.  More  than  half  (55.1  per  cent)  of  all  the  positive  cases  had 
stated,  previous  to  blood  examination,  that  they  had  had  one  or  more 
attacks  of  malaria  during  the  preceding  twelve  months;  while  72.4  per 
cent  of  those  who  carried  gametes  had  given  a  positive  history.  Thus, 
as  is  to  be  expected,  the  history  index  is  shown  to  be  more  trustworthy 
when  gametes  are  in  the  blood  than  when  they  are  not. 


EXPERIMENTS  AT  MOUND 

At  Mound,  Louisiana,  during  the  malaria  seasons  of  the  years  1920 
and  1921,  representatives  of  the  United  States  Bureau  of  Entomology 
and  of  the  International  Health  Board  have  conducted,  along  parallel 
lines,  various  field  studies  and  experiments  In  malaria  control  in  which 
the  United  States  Bureau  of  Fisheries  and  the  United  States  Bureau  of 
Plant  Industry  have  co-operated  with  the  Bureau  of  Entomology.  The 
investigations  have  dealt  with  control  by  screening,  by  the  relocation  of 
houses,  by  killing  adult  mosquitoes  In  the  houses,  by  using  mosquito  net- 
ting over  beds,  and  by  impounding  the  water  of  bayous  and  depending 
upon  top  minnows  and  wave  action  to  keep  down  breeding.  As  an  inci- 
dental feature  of  the  experiment  In  relocating  houses,  Dr.  C.  G.  Bull  of 
the  Johns  Hopkins  School  of  Hygiene  has  co-operated  in  developing 
a  technique  for  determining  definitely  the  sources  of  blood  meals  of 
mosquitoes. 


I  Dr.  Bass's  final  report  will  give  full  details  as  to  the  method  followed  in  col- 
lecting and  staining  blood  specimens  and  in  microscopically  examining  specimens 
for  the  malaria  parasite,  as  well  as  his  observations  on  the  relative  accuracy  of 
different  persons  who  examine  specimens  in  the  laboratory  and  on  various  other 
technical  subjects  which  were  investigated  in  an  effort  to  work  out  a  thoroughly 
satisfactory  method  of  diagnosis. 

13 


198 


THE  ROCKEFELLER  FOUNDATION 


Impounding  Water  Experiment   Highly   Promising.     Only 

onebf  the  experiments — that  of  impounding  water  in  bayous  which  can- 
not be  drained — has  proceeded  sufficiently  far  for  definite  conclusions  to 
be  reached.  This  method,  which  was  developed  originally  by  the  Bureau 
of  Entomology  and  given  further  test  through  the  co-operation  of  the 
International  Health  Board,  has  yielded  results  far  beyond  expectation. 
The  bayous  of  the  Mississippi  delta  are  streams  flowing  through  chan- 
nels cut  by  the  river  at  flood.  By  means  of  damming,  the  bayous  are 
converted  into  a  series  of  lakes.     The  marginal  zone  is  transformed  into 

a  pasture  by  removing  tangled 
undergrowth  along  the  edges,  and 
domestic  animals  are  introduced 
to  crop  close  the  vegetation  along 
the  water's  edge  and  permit  the 
waves  and  top  minnows  to  act 
effectively.  The  maintenance  of 
a  water  level  sufficiently  high  to 
suppress  the  growth  of  aquatic 
and  semi-aquatic  vegetation,  and 
a  clear  margin,  are  the  essential 
conditions  of  success. 


Fig.  60. — Proportionate  rates  of 
sickness  from  malaria  and  other 
diseases  among  rural  population  of 
seven  counties  in  Southeast  Missouri. 
Malaria  caused  57  per  cent  of  the 
total  illness;  digestive  diseases,  14 
per  cent;  respiratory  diseases,  11 
per  cent;  systemic  infections  (ex- 
cluding malaria),  6  per  cent;  nervous 
diseases,  2  per  cent.  Ten  per  cent 
of  the  diseases  could  not  be  classified 


Results  of  Impounding 
Experiment.  A  survey  made 
more  than  a  year  after  the  com- 
pletion of  impounding  gave  only 
one  collection  of  Anopheles  larvae 
within  the  zone  of  control.  Above 
and  below  it  numerous  specimens 
were  obtained.  The  elimination 
of  Anopheles  breeding  in  the  im- 
pounded section  seemed  to  be  the 
result  of  several  factors,  among 
which  were:  increased  water 
depth,  wave  action,  absence  of 


vegetation  near  shores,  absence 
of  small  organic  and  inorganic  particles  derived  from  submerged  d6bris 
and  vegetation,  and  finally  larval  reduction  by  fish. 

Economic  Return.  Apart  from  the  elimination  of  Anopheles 
breeding,  several  economic  advantages  resulted  from  the  impounding 
experiment.  Much  additional  pasturage  was  opened  up;  animals  were 
provided  with  plenty  of  clean  water  throughout  the  dry  season;  and  the 
supply  of  large  edible  fish  became  more  abundant  through  the  increased 
breeding  produced  under  the  more  favorable  conditions  of  the  artificial 
lakes.  The  work  of  clearing  the  ground  and  constructing  the  dams 
cost  only  a  little  more  than  3600. 


INTERNATIONAL  HEALTH   BOARD 


199 


CASES  PER  100  POPULATION 


A   MALARIA  SURVEY  IN  SOUTHEASTERN  MISSOURI 

In  counties  or  communities  where  the  physicians  and  the  people  do  not 
recognize  malaria  as  an  outstanding  public  health  problem,  surveys  are 
necessary  to  determine  the  advisability  of  using  public  funds  for  its  pre- 
vention. From  August  to  December,  1921,  Dr.  Mark  F.  Boyd  of  the 
Board's  field  staff,  in  service  with  the  Missouri  State  Board  of  Health,  con- 
ducted such  a  survey  in  a  group  of  seven  counties  containing  a  rural  popu- 
lation of  147,845,  constituting  the  southeastern  corner  of  the  state.  He 
selected  for  intensive  study 
a  typical  rural  area  of  about 
141  square  miles,  contain- 
ing a  population  of  2,966. 
Some  of  his  findings  are  in- 
teresting and  significant. 

These  counties  lie  on  the 
northern  border  of  the 
recognized  malaria  zone  for 
the  United  States,  and  yet 
Dr.  Boyd  finds  malaria  re- 
sponsible for  nearly  60  per 
cent  of  the  illness.  About 
12  per  cent  of  the  entire 
rural  population  in  the  low- 
lands was  found  infected, 
with  an  estimated  general 
malaria  incidence  of  about 
20  per  cent.  Of  the  people 
having  attacks  of  malaria 
about  36  per  cent  consult  a 
physician;  about  16  per  cent 
have  no  treatment;  and  the 
remainder  dose  themselves 
with  chill  tonics  or  quinine. 


TIGHT  HOUSE. 

POOR  OR  PARTIAL 

SCREENS 


TIGHT  HOUSE. 

POOR  OR  PARTIAL 

SCREENS 


Fig.  61. — Effect  of  screening  and  con- 
struction of  houses  on  incidence  of  malaria, 
two  Southeast  Missouri  townships 


None  were  found  who  had  received  what  is 
regarded  as  the  minimal  dosage  of  quinine  necessary  to  make  a  cure 
reasonably  certain.  The  people  living  in  open,  unscreened  houses  have 
four  times  as  much  malaria  as  those  living  in  well-built  and  well-screened 
dwellings.  Difference  in  degree  of  protection  against  mosquitoes  seems 
to  be  mainly  responsible  for  the  fact  that  the  infection  rate  was  found 
among  farm-hands,  14.6  per  cent;  among  tenants,  10.2  per  cent;  and 
among  proprietors,  7.3  per  cent. 

The  outstanding  fact  is  that  malaria  in  this  region  is  on  the  decline; 
and  that  the  principal  cause  of  the  decline  is  systematic  agricultural 
drainage.  Dr.  Boyd's  conclusion  is  that  in  this  region  anopheline  con- 
trol as  a  health  measure  is  not  economically  feasible;  and  that  the  key 
to  the  control  of  the  residual  malaria  lies  in  improving  housing  conditionF 
to  provide  better  protection  against  mosquitoes  and  educating  the  doc- 
tors and  the  people  in  proper  standards  of  malaria  treatment  and  the 
importance  of  effecting  a  cure  (see  Fig.  61). 


FIGHTING  MOSQUITOES  WITH   FISH 

Fish  played  during  1921  a  most  important  role  in  practically  all  the 
operations  conducted  against  yellow  fever  and  malaria.  During  the 
twenty  years  that  have  elapsed  since  1900,  when  the  United  States 
Bureau  of  Fisheries  began  its  investigations  into  the  usefulness  of  the 
top  minnow  for  destroying  mosquito  larvae,  many  experiments  in  the 
use  of  fish  to  keep  down  mosquito  breeding  had  been  made  in  various 
parts  of  the  world,  and  some  of  them  had  yielded  valuable  and  far- 
reaching  results.  Among  them  may  be  mentioned  the  work  of  the  New 
Jersey  Agricultural  Experiment  Station  during  the  years  1902  to  1911;  the 
observations  of  Geiger  on  the  use  of  fish  in  rice  fields  near  Lonoke,  Arkan- 
sas; and  the  experimental  work  of  Hildebrand,  of  the  United  States 
Bureau  of  Fisheries,  near  Augusta,  Georgia,  and  elsewhere.  Investi- 
gators in  a  number  of  other  countries,  particularly  in  India,  have  also 
made  valuable  contributions. 

But  the  effectiveness  of  fish  as  a  means  of  checking  the  breeding  of 
malaria  mosquitoes  was  first  demonstrated  under  representative  agricul- 
tural conditions  in  an  experiment  carried  out  by  Dr.  H.  H.  Howard  in 
Hinds  county,  Mississippi,  during  the  years  1918  and  1919.  In  a  dis- 
trict thirty-six  square  miles  in  extent,  with  a  population  of  830  living 
in  172  homes,  mosquito  breeding  was  successfully  controlled  by  the  use 
of  fish  aided  by  only  two  inspectors.  Fish  were  also  used  as  an  auxiliary 
but  very  effective  measure  of  mosquito  control  in  the  campaign  against 
yellow  fever  in  Guayaquil  in  1918  and  1919. 

Elimination  of  Stegomyia  Breeding  Places  in  Guayaquil. 

In  the  city  of  Guayaquil,  Ecuador,  the  main  breeding  places  of  the  yellow 
fever  mosquito — the  large  water-tanks — were  covered  and  sealed,  and 
fish  were  placed  in  the  many  smaller  water  containers  that  could  not  be 
so  treated.  The  covering  of  the  tanks  greatly  reduced  the  number  of 
yellow  fever  cases;  the  use  of  fish  in  the  smaller  containers  completed  the 
eradication  of  the  disease.  Since  then  there  has  not  been  a  single  case  of 
yellow  fever  in  Guayaquil.  During  1920,  at  a  time  when  the  supply  of 
fish  was  temporarily  exhausted,  the  percentage  of  containers  other  than 
tanks  in  which  yellow  fever  mosquitoes  were  breeding  rose  rapidly  from 
two  to  ten.  The  use  of  fish  effected  a  notable  economy  in  the  cost  of 
the  campaign,  making  possible  a  reduction  of  the  inspection  personnel 
from  139  to  20. 

Fish  the  Main  Reliance  in  Peruvian  Yellow  Fever  Epidemic, 
1920-1921.  For  combating  the  severe  yellow  fever  epidemic  in  Peru 
during  1920-1921,  Dr.  Hanson  discontinued  emptying  and  filtering 
and  used  fish  in  all  classes  of  containers.  The  total  of  750,000  fish  that 
had  been  distributed  by  the  end  of  1921,  brought  down  the  mosquito 

200 


Fig.  62. — Several  phases  of  yellow  fever  operations  In 
Mexico  and  Central  America.  Home  with  water  tank  well 
screened;  inspectors  examining  water  barrels  to  detect  pos- 
sible Stegomyla  breeding;  fish  distributor  on  way  to  land- 
ing place;  oilers  visiting  homes  to  oil  wells  and  small  pools 


Fig.  63. — ^Tank  at  Collma,  Mexico,  from  which  are  dis- 
tributed the  small  fish  placed  in  water  containers  at  the 
homes.  The  fish  devour  the  larvae  of  yellow  fever  mos- 
quitoes in  water  containers 


Fig.  64. — Transporting  fish  from  landing  place  to  head- 
quarters. Operations  against  yellow  fever  in  Tuxpan, 
Mexico 


INTERNATIONAL    HEALTH    BOARD  203 

index  and  held  it  to  a  safe  limit  over  the  territory  lying  between  the  sea 
and  the  mountains  and  extending  from  the  borders  of  Ecuador  to  Lima, 
a  region  500  miles  long  and  from  fifty  to  seventy-five  miles  wide.  Dr. 
Hanson  states  that  in  his  opinion  the  control  of  breeding  over  so  vast  an 
area  would  have  been  impossible  but  for  the  use  of  fish. 

Fish  the  Chief  Weapon  in  Mexican  Yellow  Fever  Campaign, 

1920-1921.  The  successful  use  of  fish  in  other  regions  led  to  their 
being  adopted  by  Le  Prince  in  the  summer  of  1920  for  the  eradication  of 
yellow  fever  in  and  around  Tampico.  The  plan  adopted  for  this  city 
and  the  oil  camps  adjacent  to  it  consisted  of  an  intensive  fish  campaign 
in  which  every  type  of  water  container  was  stocked  with  suitable  fish. 
As  supplementary  aids,  and  for  securing  control  in  bodies  of  water  in 
which  fish  were  not  effective,  oiling  and  other  methods  were  resorted  to. 
From  a  visit  to  about  500  homes  in  the  city  of  Tampico  in  1921,  Dr. 
Connor  estimated  that  the  use  of  fish  had  yielded  an  80  per  cent  degree 
of  control. 

a.  Use  of  fish  in  Vera  Cruz.  Dr.  Caldwell,  director  of  the  yellow  fever 
control  campaign  in  and  around  Vera  Cruz  in  1921,  after  visiting  Tampico 
in  1920  to  familiarize  himself  with  Le  Prince's  methods,  decided  upon  a 
campaign  along  similar  lines  for  Vera  Cruz.  Fully  one  half  of  the  con- 
tainers in  this  city  were  of  a  type  that  held  but  little  water  and  could 
be  easily  emptied.  For  these,  frequent  inspection  with  emptying  and 
cleaning  proved  to  be  the  most  satisfactory  method  of  control.  Con- 
tainers of  the  other  large  class,  including  barrels,  pozos,  and  tanks,  were 
covered  where  practicable.  Where  this  could  not  be  done,  the  introduc- 
tion of  fish  gave  highly  satisfactory  control.  For  the  few  containers  and 
other  breeding  places  that  could  not  be  covered  and  in  which  fish  could 
not  be  used,  it  was  necessary  to  resort  to  oiling. 

h.  Fish  prove  effective  in  Merida.  In  Merida,  Yucatan,  the  aljibe 
(stone  cistern  constructed  under  the  patio)  was  the  preferred  breeding 
place  of  the  Stegomyia.  Next,  in  the  order  named,  came  tanks,  barrels, 
lejia,  and  smaller  containers.  To  free  the  aljibe  of  breeding,  fish  were 
resorted  to  because  covering  was  too  expensive.  Fish  were  also  em- 
ployed with  excellent  results  in  barrels,  tanks,  and  other  large  containers. 
Small  containers  were  emptied  and  their  number  reduced  as  much  as 
possible.  Dr.  Connor,  in  his  report  for  May,  1921,  says  that  of  12,324 
water  containers  in  which  fish  were  used,  inspection  revealed  not  a  single 
one  harboring  larvae  or  pupae. 

Use  of  Fish  in  Central  America.  In  Nicaragua  fish  played  a 
part  in  controlling  the  outbreak  of  yellow  fever  in  Managua  in  August, 
1919.  They  were  not  generally  used  in  that  country,  however,  until 
early  in  1921.  Dr.  MoUoy  reports  that  they  disappear  from  small  pilas 
filled  by  taps,  and  from  rain  barrels,  when  the  water  runs  over.  In 
tanks,  and  in  pilas  filled  from  wells,  however,  they  have  given  excellent 
results. 

In  the  malaria  control  studies  conducted  in  the  department  of  Rivas, 
Nicaragua,  during  1921,  small  fish  of  the  Poeciliidae  species  were  relied  on 


204      THE  ROCKEFELLER  FOUNDATION 

exclusively  to  control  breeding  in  streams  and  ponds.  With  proper 
clearing  away  of  the  underbrush  and  cleaning  of  the  banks — a  very  inex- 
pensive process — they  yielded  satisfactory  control.  To  eliminate  the  prin- 
cipal breeding  places  of  the  region  it  was  necessary  merely  to  clean  and 
straighten  the  banks  of  two  rivers  and  give  the  top  minnows  a  chance  to 
perform  their  work.  Fish  were  also  used  with  excellent  results  to  stop 
mosquito  breeding  in  the  artificial  containers  and  wells  found  around 
houses. 

In  Salvador  fish  played  an  important  role  in  maintaining,  with  a  mini- 
mum inspection  force,  low  mosquito  indices  in  the  principal  cities.  From 
hatcheries  established  in  San  Salvador  and  Sonsonate  and  in  the  Oriente, 
fish  were  widely  distributed.  In  the  opinion  of  Dr.  Bailey  fish  alone 
would  completely  eliminate  mosquito  breeding  if  it  were  possible  to  secure 
proper  care  for  all  distributed  and  if  the  thousands  of  small  containers  in 
which  they  cannot  be  used  could  be  emptied  regularly  or  done  away 
with. 

A  striking  example  of  the  part  fish  played  in  mosquito  control  is  re- 
ported from  the  city  of  Sonsonate,  Salvador.  Even  with  persistent  inspec- 
tion of  containers  for  many  weeks  it  was  practically  impossible  to  reduce 
the  house  index  below  4.2  per  cent.  Fish  were  then  introduced,  and  in 
a  very  short  time  the  index  was  reduced  to  0.6  per  cent.  One  year  after 
the  disappearance  of  yellow  fever  from  Sonsonate,  fish  distribution  was 
suspended,  with  the  result  that  the  percentage  of  houses  in  which  Steg- 
omyia  were  breeding  rose  rapidly  from  about  1  to  9  and  the  breeding  in 
containers  from  0.4  to  5.3  per  cent. 

In  Guatemala  fish  have  been  effective  in  the  classes  of  containers  in 
which  they  can  be  used,  but  Dr.  Vaughn  reports  that  of  the  30,000  con- 
tainers in  the  yellow  fever  zone  of  that  country  only  2,900  are  suitable 
for  the  use  of  fish.  The  larvae  in  those  into  which  fish  were  introduced 
were  greatly  reduced  in  numbers  despite  the  high  mortality  of  the  fish 
and  the  difficulty  of  keeping  the  containers  adequately  stocked. 

Control  of  Malaria  in  the  Southern  States.  In  the  Southern 
States  fish  are  being  extensively  used  to  control  the  breeding  of  the 
malaria  mosquito.  In  practically  all  the  towns  in  which  there  have  been 
demonstrations  of  malaria  control  by  anti-mosquito  measures  during 
1920  and  1921,  they  have  been  an  important  auxiliary  to  drainage  and 
oiling  and  in  many  instances  the  chief  or  even  sole  reliance. 

In  a  group  of  five  counties  in  Alabama  practically  every  farmer  has  con- 
venient access  to  a  minnow  hatchery  from  which  he  is  able  to  stock  breed- 
ing places  with  fish  as  occasion  arises.  The  city  of  Richmond,  Virginia, 
has  stocked  all  its  fountains,  reservoirs,  and  lakes  with  top  minnows, 
and  has  established  hatcheries  to  furnish  the  fish  free  of  charge  to  any 
cottimunities  in  the  State  that  want  them. 

Kinds  of  Fish  to  be  Used.  In  each  locality  a  special  study  must 
be  made  of  the  kinds  of  fish  available,  of  their  habits,  and  of  the  condi- 
tions under  which  they  are  to  be  used.  It  is  not  safe  to  assume  that 
because  a  certain  species  eats  mosquito  larvae  in  the  laboratory,  it  will 


INTERNATIONAL  HEALTH   BOARD  205 

be  useful  in  an  anti-mosquito  campaign.  The  larvae-eating  habits  of 
the  species  must  be  studied  under  conditions  that  closely  approach  those 
under  which  it  is  to  be  used.  All  authorities  agree  that  an  indigenous 
fish  is  preferable.  If  an  indigenous  variety  is  not  used,  the  imported 
species  must  be  thoroughly  acclimatized  and  allowed  to  adjust  itself 
gradually  to  its  new  habitat.  Small  fish  of  the  family  Poeciliidae,  widely 
distributed  throughout  the  tropical  and  temperate  zones,  are  the  ones 
most  extensively  employed. 


VI 
COUNTY  HEALTH  WORK 


The  county  offers  a  most  effective  unit  of  organization  for  providing 
adequate  health  service  to  the  smaller  towns  and  rural  communities. 
The  need  of  such  service  was  strikingly  demonstrated  by  field  investiga- 
tions conducted  in  the  Southern  States  between  the  years  1910  and  1915. 
Study  of  the  sanitary  conditions  surrounding  274,420  homes  in  747 
counties  in  eleven  states  showed  that  only  12,145,  or  4.4  per  cent,  had 

latrine  accommodations  that 
could  be  regarded  as  satisfac- 
tory for  the  prevention  of  soil- 
borne  diseases.  One  hundred 
thirty-four  thousand  and  eight, 
or  48.8  per  cent  of  the  homes, 
had  no  latrines;  128,267  others, 
or  46.7  per  cent  of  the  total,  had 
the  grossly  Insanitary  open-seat 
surface  latrines.  Only  here  and 
there  were  county  health  de- 
partments maintained,  but  in 
such  counties  the  sanitary  con- 
ditions were  better  at  the  time 
of  original  Inspection,  it  was 
easier  to  secure  needed  improve- 
ments, and  the  advantages,  once 
gained,  were  seldom  lost. 

In  the  development  of  county 
health  work  the  Board  has  been 
serviceable  in  providing  funds 
for  initial  demonstrations.  Its 
contributions  have  stimulated 
appropriations  by  counties  and 
legislatures;  and  the  demonstra- 
tions thus  supported  are  creating  a  sustaining  public  sentiment.  The 
state  and  county  appropriations  usually  show  wholesome  growth  from  year 
to  year,  and  are  seldom  reduced  even  in  the  face  of  the  severe  economic 
depression  that  has  necessitated  curtailment  of  many  useful  forms  of 
service. 

SCOPE  AND  EXTENT   OF   SERVICE 

During  the  year  1921  co-operative  projects  in  county  health  organiza- 
tion were  carried  out  with  the  Board's  participation  In  seventy-seven 
counties  in  sixteen  states.    The  total  sum  appropriated  by  all  the  agen- 

206 


Fig.  65. — Growth  in  funds  set  aside 
for  county  health  work,  nine  south- 
ern states,  1917-1921.  Includes 
appropriations  by  states,  counties. 
International  Health  Board,  and 
other  agencies 


INTERNATIONAL   HEALTH   BOARD 


207 


cies  which  co-operated  in  these  projects  was  $758,904,  of  which  the  coun- 
ties themselves  provided  3344,081,  the  state  boards  of  health  3156,658, 
and  the  Board  3177,777.  The  re- 
maining 380,387  came  from  other 
sources,  including  the  United  States 
Public  Health  Service  and  the  Ameri- 
can Red  Cross,  or  from  municipalities 
and  private  corporations  or  indi- 
viduals. 

During  the  year  1921  new  work 
was  begun  or  arrangements  for  be- 
ginning it  were  completed  in  five 
states  in  addition  to  the  twelve^  in 
which  it  was  previously  in  prog- 
ress. These  five  states  were  Florida, 
Indiana,  Louisiana,  Maryland,  and 
Missouri.  There  was  thus  a  total 
of  seventeen  states  in  which  opera- 
tions were  under  way  or  contemplated 
at  the  close  of  the  year.  The  exten- 
sion of  the  work  has  been  most  rapid 
in  North  Carolina,  which  now  has 
twenty-seven  full-time  health  de- 
partments, and  in  Alabama,  which 
has  eighteen. 

The  plan  of  work  pursued  by  the 
county  health  departments  has  been 
evolved  from  experience,  is  applicable 
under  a  wide  variety  of  conditions, 
and  has  stood  the  test  of  time. 
Though  there  are  minor  diff'erences 
to  meet  local  conditions,  the  most 
important  activities,  which  are  more 
or  less  common  to  all  the  units,  group 
themselves  under  the  following  main 
heads:  (1)  public  health  education; 
(2)  sanitation;  (3)  control  of  com- 
municable diseases;  (4)  adult  and 
child  hygiene.  The  demonstrations 
are  so  planned  as  to  enable  any 
county  to  undertake  at  the  start,  in 
a  small  way  and  with  the  least  ex- 
penditure of  money,  the  line  or  lines 
of  work  which   for   that   particular 

county   give   promise   of  yielding   the   greatest  results  in  lives  saved 
and  sickness  prevented.    Other  activities  are  added  and    the  health 


Fig.  66. — Reduction  of  hook- 
worm infection  rates,  1911  to 
1921,  in  fifty-two  counties  in  ten 
southern  states.  Based  on  the 
original  infection  surveys  of 
1911-1914,  when  57.8  per  cent 
of  48,456  school  children  exam- 
ined were  found  infected,  and 
the  special  re-infection  surveys 
made  during  1920-1921,  when 
27.7  per  cent  of  27,524  school 
children  were  found  infected 


1  Alabama,  Georgia,  Kansas,  Kentucky,  Mississippi,  New  Mexico,  North  Carolina, 
South  Carolina,  Tennessee,  Texas.  Virginia,  West  Virginia. 


208 


THE  ROCKEFELLER  FOUNDATION 


department  is  expanded  as  the  work  proves  effective  and  additional 
funds  are  provided. 


PERSONNEL   AND   BUDGET 

The  personnel  of  the  average  county  health  department  consists  of  a 
health  officer,  a  sanitary  inspector,  an  office  assistant,  and  a  public  health 

nurse,  though  the  staff  is  enlarged  as 
occasion  requires.  The  regular  per- 
sonnel serves  on  a  full-time  basis — a 
principle  that  is  considered  essential 
to  the  success  of  the  work.  The  usual 
annual  budget  for  a  county  of  average 
size  is  310,000,  though  the  amount 
may  be  increased  in  the  case  of  larger 
or  more  prosperous  counties,  or  be  re- 
duced in  counties  whose  population 
is  small  or  resources  limited.  Some- 
times two  or  more  sparsely  settled 
counties  combine  to  operate  a  health 
department. 

In  no  case  do  the  funds  appropri- 
ated for  the  health  department  bud- 
get represent  the  total  sum  that  the 
county  residents  devote  to  health  pro- 
tection. The  work  of  the  depart- 
ment invariably  stimulates  private 
expenditures  for  sanitary  and  other 
improvements  that  far  exceed  the 
amounts  of  the  county  budgets.  To 
cite  one  of  many  instances,  the  citi- 
zens of  Tazewell  county,  Virginia, 
contracted  or  paid  out  in  four  months 
during  1921  a  total  of  360,000  for 
sanitary  improvements  recommended 
by  the  health  department,  although 
the  total  budget  for  the  department 
during  this  period  amounted  to  only 
33,000. 

Public  health  nurses  are  being  em- 
ployed in  increasing  numbers.  They 
furnish  a  close  bond  of  contact  be- 
tween the  health  staff  and  the  people. 
When  a  case  of  communicable  disease 
is  quarantined  a  nurse  visits  the 
home  and  gives  advice  as  to  the  methods  to  be  followed  in  caring 
for  the  patient  and  in  preventing  the  spread  of  the  disease  to  other  mem- 
bers of  the  family  or  to  the  community;  when  children  are  found  to  be 


35 

30 

1    25 

§    20 

8 
£ 

"^     15 
tiJ 

1 

i '° 

0 
5 

0 

- 

1 

1 

YEAR 

1914 
TO 
1917 

1918 

DEATH 
RATE 

35.3 

7.8 

Fig.  67. — Average  number  of 
deaths  from  typhoid  fever  per 
hundred  thousand  population, 
nine  North  Carolina  counties. 
Record  for  years  1914  to  1917, 
before  inauguration  of  county 
health  work,  compared  with  that 
for  1918,  the  year  succeeding  its 
inauguration 


Fig.  68. — Health  officer  vaccinating  children  in  rural 
school  of  Mason  county,  Kentucky.  Small  towns  and 
rural  communities,  in  increasing  numbers,  are  providing 
themselves  with  health  service  of  a  type  that  has  usually 
been  found  only  in  large  cities 


^^^^^^H4S0^  COUNTY  WM 

[j^H 

^^^^^1       PUBLIC 

-^^n 

^^H~  ^           ^ 

H^^^^BCAini  LEAGUE  ^ 

W          '^'  ^^1 

I       Y 

M^ 

1 

Fig.  69. — Trachoma  clinic  at  Maysville,  Kentucky,  an- 
other feature  of  county  health  work  as  conducted  in  Mason 
county 


Fig.  70. — Class  of  midwives,  with  their  instructor  (second 
from  left),  Davidson  county,  North  Carolina.  Many  of 
the  county  health  departments  are  making  the  instruction 
of  midwives  an  important  feature  of  their  service 


Fig.  71. — Children  assembled  to  receive  diphtheria  im- 
munization, Tyndale  school,  Lenoir  county,  North  Caro- 
lina. The  Schick  test  and  toxin-antitoxin  are  proving 
effective  weapons  in  the  county  health  departments'  fight 
against  diphtheria 


INTERNATIONAL  HEALTH   BOARD  211 

suffering  from  defects  she  consults  with  the  parents  and  urges  them  to 
have  the  defects  promptly  corrected;  and  she  renders  valuable  assistance 
to  the  health  officer  in  the  organization  and  conduct  of  clinics,  in  secur- 
ing the  co-operation  of  established  welfare  agencies,  and  in  carrying  out 
the  general  program  of  health  education  and  community  development. 


ACTIVITIES   UNDERTAKEN 

The  report  for  1920  discussed  somewhat  in  detail  the  activities  usually 
embraced  in  the  county  health  program.  Of  the  newer  activities  under- 
taken by  several  of  the  departments  during  1921,  those  concerned  with 
county-wide  effort  for  the  control  of  malaria,  with  the  use  of  the  Schick 
test  and  toxin-antitoxin  for  the  control  of  diphtheria,  with  measures 
against  venereal  diseases,  and  with  the  improvement  of  the  physical 
condition  of  undernourished  school  children,  may  be  worthy  of  separate 
discussion. 

Anti-Malaria  Work.  The  malaria  operations  conducted  by  the 
county  health  departments  in  Alabama  have  been  fully  discussed  on 
pages  191  and  192.  In  other  states  also  the  departments  undertook 
campaigns  for  mosquito  control,  advised  suspected  cases  to  have  their 
blood  microscopically  examined  and  to  consult  a  physician  with  regard 
to  standard  treatment  if  found  positive,  and  in  some  instances  they  sup- 
plied free  quinine  in  malarious  districts.  In  the  towns  of  Greenville 
and  Farmville,  North  Carolina,  it  is  reported  that  as  a  result  of  the  anti- 
malaria  work  conducted  during  the  past  two  years  under  the  direction  of 
the  Pitt  county  health  department,  malaria  was  reduced  at  least  75  per 
cent. 

Control  of  Diphtheria  and  Venereal  Diseases.  The  health  de- 
partments in  many  of  the  counties  made  extensive  use  of  the  Schick  test 
and  of  toxin-antitoxin  for  controlling  epidemics  of  diphtheria  in  the  late 
summer  and  fall  of  1921,  when  the  disease  became  quite  prevalent  in 
many  counties;  and  in  other  instances  effort  was  devoted  throughout  the 
year  to  the  control  of  venereal  diseases.  The  measures  against  the  latter 
disease  consisted  in  the  main  of  clinics,  the  closing  of  houses  of  prostitu- 
tion, and  caring  for  sufferers  to  insure  their  treatment  until  cured. 

Nutritional  Work  in  the  Schools.  The  nutritional  work  un- 
dertaken in  a  number  of  counties  effected  much  improvement  not  only  in 
the  weight  of  the  children  but  also  in  their  ability  to  keep  up  with  their 
studies  at  school.  In  Montgomery  county,  Tennessee,  373  pupils  from 
thirteen  rural  schools  gained  in  weight  within  three  to  fifteen  weeks  an 
average  of  three  pounds  each  as  a  result  of  such  simple  measures  as  serv- 
ing them  daily  with  milk  and  hot  lunches  and  urging  them  to  observe 
precautions  in  the  care  of  the  teeth,  sleeping  with  windows  open,  and  tak- 
ing daily  a  sufficient  amount  of  outdoor  exercise.  In  one  of  the  largest 
schools  in  this  county,  with  700  pupils,  the  percentage  of  underweight 
children  was  reduced  during  the  school  term  of  1921  from  36  to  14.     In 


212      THE  ROCKEFELLER  FOUNDATION 

Blount  county  of  the  same  state  883  children  gained  in  the  same  period  an 
average  of  6.2  pounds. 

Miscellaneous  Newer  Activities.  In  several  South  Carolina  coun- 
ties the  local  physicians  organized  and  held  during  1921  free  clinics  for 
the  treatment  of  general  diseases,  with  especially  good  results  in  Green- 
wood county;  and  in  Kentucky  and  Tennessee,  where  trachoma  is  widely 
prevalent  in  certain  sections,  a  large  number  of  clinics  were  held  for  the 
relief  of  this  disease.  In  all  the  counties  the  problem  of  insuring  pure 
milk  supplies  is  receiving  early  attention.  For  this  purpose  some  of  the 
units  have  added  to  their  staffs  a  veterinarian  who  inspects  the  product  of 
dairies  and  other  milk-handling  establishments  and  requires  that  it 
be  brought  up  to  standard. 


RESULTS  ACCOMPLISHED 

The  co-operative  projects  carried  out  during  the  year  1921  hate  yielded 
results  whose  value  exceeds  by  many  times  the  sums  appropriated. 
During  the  year,  in  addition  to  the  results  accomplished  in  other  lines  of 
effort,  new  latrines  were  installed  or  old  latrines  improved  and  made 
sanitary  at  a  total  of  34,186  homes;  13,450  cases  of  communicable  dis- 
eases were  quarantined;  257,526  vaccinations  were  given  for  typhoid 
fever  and  83,467  for  smallpox;  and  257,319  school  children  were  exam- 
ined for  physical  defects. 

Reduction  in  Typhoid.  Figures  26,  66,  67,  and  72,  pages  125,  207, 
208,  and  213,  exhibit  some  of  the  instances  of  marked  reduction  in  sick- 
ness and  death  that  have  been  reported.  In  Alabama  typhoid  fever 
declined  60  per  cent  in  the  four-year  period  from  1917  to  1921 — a 
period  that  exactly  coincides  with  the  bringing  of  the  city  water  sup- 
plies throughout  the  state  under  the  direction  of  the  state  health  de- 
partment and  with  the  placing  of  more  than  45  per  cent  of  the  state's 
inhabitants  under  the  protection  of  county  health  departments.  In  a 
section  of  Smith  county,  Tennessee,  where  for  many  years  there  had 
been  a  high  incidence  of  typhoid  fever,  a  remarkable  reduction  resulted 
from  an  intensive  vaccination  campaign  in  1919.  During  the  four-year 
period  from  1916  to  1919,  inclusive,  there  were  in  this  area  twenty-one 
deaths  from  typhoid  fever  and  more  than  200  cases.  During  1920  not 
a  single  case  of  the  disease  was  reported.  In  Blount,  Montgomery, 
Roane,  and  Smith  counties  the  average  number  of  deaths  per  year  from 
typhoid  fever  during  the  period  from  1915  to  1919  was  48.2.  For  the 
two-year  period  1920-1921,  following  the  organization  of  county  health 
work,  the  number  fell  to  22.2,  a  reduction  of  53.9  per  cent.  In  Blount 
county  the  authorities  estimate  that  a  saving  of  369,080  resulted  from 
the  service  rendered  by  the  county  unit  in  reducing  the  incidence  of 
typhoid  fever. 

Control  of  Smallpox,  Diphtheria,  and  Other  Epidemics.     In 

Daviess,  Harlan,  and  Scott  counties,   Kentucky,  where  in  former  years 


iNTERNAxIOiSTAL  HEALTH   BOARb 


213 


smallpox  claimed  a  heavy  toll,  epidemics  were  averted  in  1921  by  the 
prompt  action  of  the  county  health  departments.  In  neighboring  counties 
the  disease  was  rife.  In  Harlan  county  the  highest  number  of  cases 
prevailing  at  any  one  time  in  1921  was  eighteen,  as  compared  with  more 
than  500  in  the  adjoining  county  of  Bell,  which  had  then  no  county  health 
department.  In  Scott  county  only  thirty-one  cases  of  the  disease  oc- 
curred, which  were  limited  to  fifteen  homes;  and  in  Daviess  county  only 
twelve  cases  developed  during  the  months  of  April,  May,  and  June,  1921, 
as  compared  with  185  cases  for  the  same  period  in  1920.  In  Geary 
county,  Kansas,  during  1921,  the  department  more  than  paid  for  itself 


Fig.  72. — Control  of  typhoid  fever  in  Pearl  River  county,  Mississippi, 
incidental  to  the  county-wide  efforts  to  guard  against  pollution  of  the 
soil 


by  preventing  a  threatened  invasion  of  smallpox.  In  this  county  there 
were  only  fourteen  cases  of  this  disease,  all  of  which  were  treated  in  their 
own  homes.  In  an  adjoining  county  the  disease  reached  alarming  pro- 
portions, necessitating  the  establishment  of  an  emergency  pest-house 
at  an  initial  cost  of  35,000,  a  sum  greater  than  that  provided  by  the 
residents  of  Geary  county  for  maintaining  their  health  department  for 
one  whole  year. 

In  Williamson  and  Montgomery  counties,  Tennessee,  what  threatened 
to  be  serious  diphtheria  epidemics  were  checked  by  the  prompt  action  of 
the  county  health  departments  in  examining  contacts  and  isolating  car- 
riers and  positive  cases.  Scott  county,  Kentucky,  has  had  in  the  past 
two  years  only  one  death  from  diphtheria,  whereas  several  neighboring 


514      THE  ROCKEFELLER  FOUNDATION 

Kentucky  counties  without  full-time  health  departments  have  had  as 
many  as  twenty  or  more.  In  the  city  of  Santa  F6,  New  Mexico,  a  threat- 
ened outbreak  of  scarlet  fever  was  completely  checked  by  daily  inspection 
of  school  children  and  exclusion  of  suspects.  The  people  had  become 
much  alarmed  when  this  infection  appeared  in  1921,  as  several  years 
before  there  had  been  a  persistent  and  widespread  outbreak  with  the 
deaths  running  as  high  as  fifteen  a  day. 

Reduction  of  Hookworm  Incidence.  The  hookworm  resur- 
veys  carried  out  during  1920  and  1921  (see  discussion,  pages  124  to  126) 
showed  that  the  reduction  of  hookworm  disease  has  been  greatest  in  the 
counties  in  which  county  health  departments  have  been  in  operation. 
This  result  may  be  attributed  not  only  to  the  treatment  of  infected  per- 
sons but,  and  more  particularly,  to  the  improvement  in  sanitation  that 
has  been  effected  in  recent  years.  The  resurveys  in  their  turn  have 
proved  effective  in  stimulating  public  interest  in  further  hookworm  con- 
trol and  in  general  health  work.  In  Baldwin  county,  Alabama,  the 
authorities  estimate  that  hookworm  disease  is  costing  the  county  not 
less  than  3100,000  annually,  and  the  systematic  work  of  the  county  health 
department  is  gradually  eliminating  this  loss. 

CONTINUATION  AND  EXPANSION 

The  educational  value  of  the  work  and  the  demonstration  of  the  bene- 
fits to  be  derived  from  it  find  strongest  expression  in  the  action  of  the  coun- 
ties year  by  year  in  providing  for  its  continuation  and  expansion.  Coin- 
cident with  the  increase  in  funds  there  has  been  steady  increase  in  the 
personnel  engaged.  The  benefits  of  the  work  in  one  county,  being  seen 
and  appreciated  in  adjoining  counties,  have  led  to  demands  for  similar 
work.  In  Kentucky  during  1921,  for  example,  six  additional  counties — 
all  of  them  adjoining  counties  in  which  work  was  already  in  progress — 
laid  the  foundation  for  whole-time  health  departments  to  be  organized 
later. 

The  state  of  Ohio,  which  maintains  its  county  health  work  independ- 
ently of  outside  assistance,  stands  at  the  head  of  the  list  of  states  with 
respect  to  the  number  of  counties  having  whole-time  health  departments. 
In  Virginia,  Alabama,  Georgia,  and  North  Carolina,  however,  the  num- 
ber of  co-operative  county  projects  has  increased  with  great  rapidity. 
The  work  has  also  spread  from  state  to  state  until,  at  the  close  of  1921, 
it  was  no  longer  confined  to  the  Southern  States  but  was  under  way  or 
contemplated  in  practically  all  sections  of  the  country. 

Not  only  are  departments  once  established  usually  continued,  but  the 
appropriations  for  maintaining  them  are  enlarged  year  by  year,  the  range 
of  activities  undertaken  is  broadened,  and  in  the  end  the  departments, 
usually  established  at  first  on  a  trial  basis  for  a  period  of  one  to  three  years, 
have  been  made  permanent  as  the  results  they  achieved  have  demon- 
strated to  the  people  the  wisdom  of  continuing  them.  As  illustrating 
the  manner  in  which  the  funds  made  available  for  the  work  are  increased 
year  by  year,  the  record  for  the  following  five  counties  may  be  cited: 


INTERNATIONAL  HEALTH   BOARD  215 


I9I7 

I9I8 

1919 

1920 

192 1 

$4,400 

$6,600 

16,400 

I3.S00 

lio.ooo 

3.48s 

6,20s 

S.66S 

8,870 

12,196 

3.485 

6,205 

5.66s 

8.741 

9,000 

2,904 

6,332 

5. 702 

8,232 

9,000 

2.904 

6,332 

S.702 

8,482 

9,000 

Mason  county,  Ky. 
Wilson  county,  N.  C. 
Davidson  county,  N.  C. 
Northampton  county,  N. 
Lenoir  county,  N.  C. 


COUNTY   HEALTH  WORK   IN   OTHER   COUNTRIES 

As  county  health  work  in  the  United  States  has  been  developed  and  its 
various  lines  of  procedure  have  become  established  on  a  fairly  satisfac- 
tory basis,  it  has  in  turn  served  to  stimulate  more  active  interest  in  rural 
health  w^ork  in  other  countries.  As  a  result  the  Board  has  been  asked  to 
aid  in  conducting  demonstrations  in  general  rural  health  programs  in  a 
number  of  countries,  including  Brazil,  France,  and  Czechoslovakia. 
During  the  year  the  first  rural  health  unit  in  Brazil  was  established 
in  the  county  of  Sertaozinho,  in  the  state  of  Sao  Paulo;  and  the  pros- 
pects are  excellent  that  within  the  next  two  years  similar  work  will  be 
developed  in  the  states  of  Sao  Paulo,  Minas,  Rio,  and  Rio  Grande  do 
Sul.  With  variations  in  working  procedure  to  meet  special  conditions, 
and  with  adequate  local  appropriations  available,  it  would  seem  feasible, 
through  the  extension  of  this  type  of  work  to  rural  regions  in  many 
quarters  of  the  globe,  to  effect  the  same  reduction  in  sickness  and  death 
rates  and  the  same  promotion  of  human  welfare  that  has  attended  simi- 
lar effort  in  the  United  States. 


NOTES    ON    TABLES 


TABLE    I 


1.  Table  1  on  the  following  pages  presents  a  concise  statistical  summary 
— by  the  main  geographical  divisions  of  the  work,  by  states  and  countries, 
and  by  years — of  the  persons  examined  and  treated  in  the  world-wide 
campaign  for  the  relief  and  control  of  hookworm  disease  aided  by  the 
International  Health  Board.  It  shows  that  in  the  twelve  years  from 
1910  to  1921,  inclusive,  a  total  of  3,770,624  persons  have  been  examined 
in  thirty-four  ^  different  states  and  countries,  of  whom  2,232,756,  or 
59.2  per  cent,  were  found  infected.  Of  those  infected,  2,020,396,  or 
90.5  per  cent,  were  given  one  treatment;  while  1,352,550,  or  60.6  per  cent, 
received  two  or  more  treatments. 

2.  Two  treatments  of  a  standard  remedy  remove,  on  the  average, 
from  88  to  95  per  cent  of  the  worms  harbored,  depending  upon  the  drug 
used  and  the  method  of  administration;  and  it  is  seldom  that  they  leave 
more  than  ten  worms  in  the  intestine.  Thus,  though  some  persons  may 
remain  lightly  infected  after  two  treatments,  this  number  is  nevertheless 
adequate  to  establish  what  may  be  termed  a  "practical"  cure.  One 
treatment,  similarly,  removes  from  75  to  90  per  cent  of  the  worms. 

3.  Though  the  figures  have  been  itemized  by  states  and  countries  and 
by  years,  this  has  not  been  done  primarily  to  invite  comparison  of  the 
results  for  one  state  with  those  for  another,  or  of  one  year's  w^rk  with 
that  of  another.  Too  many  variable  factors  affect  the  results  for  such 
comparisons  to  be  entirely  valid.  For  instance,  among  other  reasons, 
the  variations  or  fluctuations  may  be  due  to  the  density  of  population 
or  severity  of  infection  in  the  areas  of  operation,  to  size  of  working  staff, 
or  to  differences  in  the  plan  of  work  pursued.  In  other  instances,  as  in 
British  Guiana  in  1919  and  Dutch  Guiana  in  1921,  the  figures  may  rep- 
resent results  for  only  a  few  months  instead  of  a  complete  year. 

4.  The  table  includes  the  results  of  the  early  dispensary  effort  aided  by 
the  Rockefeller  Sanitary  Commission  in  the  Southern  States.  These 
figures  are  not  itemized  by  years,  but  are  reported,  under  the  respective 
states,  as  the  total  for  the  years  1910  to  1914,  inclusive.  Some  of  the 
work  for  1914,  separately  indicated,  was  aided  by  the  International 
Health  Board.  Since  1915,  when  work  by  the  dispensary  plan  ceased 
in  these  states,  the  chief  effort  against  hookworm  disease  has  been  directed 


See  footnote  4,  page  228. 

216 


INTERNATIONAL    HEALTH    BOARD  217 

toward  the  building  and  use  of  latrines.  Therefore  the  aggregate  figures 
for  examination  and  treatment  are  not  so  large  as  in  previous  years,  nor 
do  they  represent  in  all  cases  such  thoroughgoing  effort  in  the  curative 
phase  of  the  work. 

5.  In  a  number  of  countries  operations  were  suspended  during  the  war 
and  resumed  after  its  close;  in  others  there  have  been  temporary  periods 
of  suspension  due  to  industrial  depression,  lack  of  trained  directors,  or 
similar  causes. 

6.  Only  the  results  of  campaigns  aided  directly  by  the  International 
Health  Board  or  Rockefeller  Sanitary  Commission  are  included.  In  a 
number  of  countries,  as  in  Brazil,  government  or  voluntary  agencies  are 
conducting  extensive  independent  campaigns  against  the  disease,  the 
results  of  which,  if  they  could  be  included,  would  substantially  increase 
the  aggregate  examinations  and  treatments. 

TABLE   2 

\.  Table  2  shows  that  in  the  work  of  the  International  Health  Board 
during  the  years  1913  to  1921,  inclusive,  a  total  of  37,493,624.25  was  ex- 
pended. The  table  is  based  on  expenditures  actually  made  during  the 
respective  calendar  years.  The  figures  differ  from  those  given  in  the 
Treasurer's  statements  forming  part  of  earlier  reports  of  the  Foundation. 
The  Treasurer's  reports  have  included  amounts  paid  in  the  field  during 
the  first  three  quarters  of  the  respective  years,  to  which  have  been  added 
in  many  instances  amounts  paid  during  the  fourth  quarter  of  one  year 
but  not  recorded  until  the  first  quarter  of  the  succeeding  year.  The  dis- 
crepancy is  caused  by  the  necessity  of  closing  the  Treasurer's  books 
shortly  after  the  first  of  each  calendar  year,  before  detailed  financial  re- 
ports can  be  received  from  countries  in  which  a  large  part  of  the  work 
of  the  Board  is  conducted. 


14 


2l8 


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230  THE   ROCKEFELLER  FOUNDATION 

TABLE  2:  Expenditures  of  the  International  Health  Board  for  the 


Activity,  State,  and 
Country 

July  1,  1913 
Dec.31,1914 

1915 

1916 

1917 

Grand  Total 

$157,731.08 

$333,461.91 

$506,087.48 

$578,367.75 

Relief  and  Control  of 
Hookworm  Disease.  . 

County  Health  Work  . 

Malaria  Control 

Yellow  Fever  Control 

Tuberculosis    in 
France  

93,202.74 

15,351.20 
15,138.35 
34,038.79 

234,592.13 

25,000.00 

9,877.95 
15,057.65 
48,934.18 

306,574.04 

54,496!  97 
41,863.17 

9,256.74 

664.39 

4,687.45 
27,628.35 
60,916.37 

369,988.49 

182.95 

39,978.58 

9,344.03 

51,856.24 

12,376.63 

Public    Health    Edu- 
cation  

Public  Health  Labora- 
tory Service 

Philippine    Hospital 
Ship 

Investigation  of  Sew- 
age  Disposal   at 
Rural  Homes 

Field   Staff  Salaries, 
Expenses,   etc.,   not 
Prorated     to     Spe- 
cific Budgets 

Miscellaneous 

Administration 

5,359.11 

9,232.30 
18,191.76 
61,857.66 

Relief  and  Control  of 
Hookworm  Disease 
Southern  States^  . . 

West  Indies 

Central  America  . . . 

South  America 

The  East 

93,202.74 

38,767  .'33 
19,552.54 

19,466!  66 
15,476.21 

234,592.13 

89,565.64 
52,393.83 
55,379.47 

37,253  .'i9 

89,565.64 

4,343.33 

22,822!  59 

9,766.49 

529.38 

11,719.14 
3,026.99 
5,872.56 

11,889.72 
8,175.55 

306,574.04 

47,565.09 
88,845.12 
88,123.29 
4,779.77 
77,260.77 

47,565.09 

4,866!  63 
1,813.19 
8,786.77 
3,282.34 
5,643.52 
5,797.57 
9,971.36 

369,988.49 

53.446.11 
87,764.12 
98,483.25 
43,309.16 
84,912.45 
2,073.40 

53,446.11 

1,235.97 
2,462.59 
2,436.95 

Miscellaneous 

Southern  States  i^ 

Alabama 

Arkansas 

Georgia 

Kentucky 

Louisiana 

Mississippi 

North  Carolina .... 

South  CaroHna 

Tennessee 

2,200.00 
1,278.66 
9,223.36 
8,548.71 
7,967.22 
6,585.02 
5,170.48 

Texas 

]  In  September,  1917,  the  hookworm  work  in  the  Southern  States  began  to  be  absorbed  in  the 
being  longer  in  some  states  than  in  others,  it  was  not  possible  to  announce  until  the  end  of  1920 
regular  functions,  responsibility  for  all  efforts  directed  toward  the  relief  and  control  of  hookworm 


INTERNATIONAL    HEALTH    BOARD  231 

Years  jgij-iQi4  to  IQ21,  Inclusive,  Covering  All  Activities 


1918 

1919 

1920 

1921 

Total 

$1,121,862.86 

$1,436,355.00 

$1,658,572.61 

$1,701,185.96 

$7,493,624.65 

457,953.94 

509,091.99 

621,520.98 

457,486.99 

3,050,411.30 

2,494.53 

2,439.25 

8,182.77 

167,765.19 

181,064.69 

26,489.29 

34,965.08 

133,929.02 

150,551.39 

440,410.33 

46,639.17 

94,526.42 

139,757.40 

239,057.53 

571,187.72 

433,030.43 

602,775.78 

518,013.51 

359,540.31 

1,965,216.27 

36,642.82 

38,367.71 

68,373.54 

89,094.44 
16,109.70 

254,111.88 
16,109.70 

12,500.00 

6,500.00 



44,000.00 

4,288.01 

778.60 

11,090.11 

5,345.82 

21,701.87 

26,074.89 

38,936.95 

131,208.43 

23,034.17 

46,901.63 

51,248.30 

59,652.90 

256,853.11 

73,444.68 

78,306.67 

91,472.20 

122,990.56 

571,961.11 

457,953.94 

509,091.99 

621,520.98 

457,486.99 

3,050,411.30 

87,284.58 

110,860.17 

136,019.06 

15,730.39 

540,471 .  04 

57,800.06 

48,457.24 

61,857.73 

85,541.60 

521,367.03 

113,545.86 

111,684.19 

98,303.98 

77,920.73 

662,993.31 

97,031.00 

157,555.86 

206,486.22 

150,422.24 

659,584.25 

97,932.47 

80,014.39 

113,472.55 

121,805.46 

632,117.94 

4,359.97 

520.14 

5,381.44 

6,066.57 

33,877.73 

87,284,58 

110,860.17 

136,019.06 

15,730.39 

540,471.04 

5,922.09 

5,283.74 

17,256.71 

34,041.84 

2,784.41 

5,247.00 

5,418.95 

'4,604.21 

4,525.39 

39,808.09 

2,064.97 

1,978.40 

16,599.03 

37,475.52 

1,317.93 

1,370.18 



6,309.34 

9,427.52 

15,773.21 

20,709.72 



75,639.72 

15,775.89 

13,924.04 

10,463.00 

55,020.97 

13,870.12 

14,754.86 

17,210.63 

65,318.91 

6,642.20 

10,201.59 

13,533.22 

54,649.32 

9,362.85 

22,380.20 

14,723.99 



69,784.43 

programs  of  the  rapidly  developing  county  departments  of  health.  The  period  of  transition 
that  in  all  the  states  the  county  health  departments  would  henceforth  assume  as  one  of  their 
and  other  soil-borne  diseases. 


232  THE  ROCKEFELLER   FOUNDATION 

TABLE  2:  Expenditures  of  the  International  Health  Board  for  the 


Activity,  State,  and 
Country 


July  1,  1913 
Dec.  31,1914 


Relief  and  Control  of 
Hookworm  Disease — 
Continued 
Southern  States — ConVd 

Virginia 

Administration 

County    Dispensary 

Work  in  the  South 

Resurveys 

West  Indies: 

Antigua 

Barbados  (survey).. 
British  Guiana^  .  .  . 
Cayman  Islands 

(survey) 

Dutch  Guiana  ^  . . . . 

Grenada 

Jamaica 

Porto  Rico 

Santo  Domingo 

(survey) 

St.  Lucia 

St.  Vincent 

Tobago  (survey) .  .  . 

Trinidad 

Administration 

Central  America: 

British  Honduras 

(survey) 

Costa  Rica 

Guatemala 

Nicaragua 

Panama 

Salvador 

Administration 

South  America: 

Brazil 

Colombia 


38,707.33 
3,780.06 


9,711.36 
7,663!  76 


4,742.30 
4,335.18 


9,134.67 


19,552.54 


9,174.60 
185.53 
375.00 

9,817.41 


1915 


$6,622.97 


4,796.92 


52,393.83 
1,738.23 


13,300.06 


3,260.93 
10,593.37 


6,048.76 
4,834.00 


8,242.19 
4,376.29 

55,379.47 


16,913.06 
10,432.69 

7,587.80 
18,828.55 


1,617.37 


1916 


$7,403.71 


88,845.12 
9,316.68 
1,651.31 

18,554.45 


11,672.46 
10,154.65 


6,295.20 
6,825.15 


15,104.04 
9,271.18 

88,123.29 

4,273.47 
18,089.98 
11,954.29 
18,430.69 
24,449.62 
10,925.24 


4,779.77 

4,779.77 


1917 


$6,337.15 


87,764.12 

4,758.87 

l'9,23i;23 

1,795.16 

19,168.40 

7,778.80 


6,865.60 
9,384.18 
1,072.22 
10,898.37 
6,811.29 

98,483.25 


21,752.31 
13,346.70 
19,418.74 
22,881.75 
21,083.75 


43,309.16 

43,309.16 


^  For  administrative  reasons  British  and  Dutch  Guiana,  although  on 


INTERNATIONAL    HEALTH    BOARD  233 

Years  igi^-igi4.  to  IQ21,  Inclusive,  Covering  All  Activities — Cont^d 


1918 


1919 


1920 


1921 


Total 


$5,947.86 
8,749.79 


57,800.06 


16,504.11 


4,389.11 
1,833.74 
3,937.85 


8,152.28 
6,383.25 


12,301.48 
4,298.24 

113,545.86 


21,330.40 
20,816.27 
22,454.30 
24,312.26 
17,573.90 
7,058.73 

97,031-00 

97,031.00 


$10,012.42 
10,577.32 


48,457.24 


9,984.28 


613.23 


9,832.48 


8.109.32 


15,293.43 
4,624.50 

111,684.19 


20,492.01 
19,514.73 
26,164.44 
18,565.05 
17,162.10 
9,785.86 

157,555.86 

155,430.38 
2,125.48 


$14,965.17 
6,032.20 


61,857.73 


486.37 


570.34 


18,400.09 


7,823.35 

1,077.07 

11,444.57 

16,616  In 

6,039.23 

98,303.98 

20,2i9!66 

17,126.43 

18,745.12 

20,061.02 

14,973.80 

7,178.01 

206,486.22 

193,560.95 

12,925.27 

15,730.39 
85,541.60 


1,281.02 


12,917.66 


16,949.24 
18,290.86 


8,545.88 
17,489.50 


10,067.44 
77,920.73 


14,061.66 
15,362.58 
21,479.43 
23,496.^ 
3,520.84 


150,422.24 

131,787.27 
18,634.97 


$51,289.28 
25,359.31 

4,796.92 
15,730.39 

521,367.03 

19,593.84 

1,651.31 

89,052.88 

1,795.16 
52,592.13 
37,364.32 
49,119.66 

26,114.21 

1,077.07 
60,203.91 
49,251.26 

1,072.22 
86,990.89 
45,488.17 

662,993.31 

4,273.47 
142,033.62 
108,739.22 
134,655.52 
162,411.88 
85,239.63 
25,639.97 

659,584.25 

625,898.53 
33,685.72 


the  mainland  of  South  America,  are  considered  West  Indian  colonies. 


15 


234  THE   ROCKEFELLER  FOUNDATION 

TABLE  2:  Expenditures  of  the  International  Health  Board  for  the 


Activity,  State,  and 
Country 

July  1,  1913 
Dec.31,1914 

1915 

1916 

1917 

Relief  and  Control  op 
Hookworm     Disease 
Continued 
The  East: 

Uncinariasis     Com- 
mission to  Orient . 
Australia 

$19,466.66 

19,466!  66 



15,476.2i 

15,476  !2i 

$37,253.19 

15,504.31 

"2,673!  07 
'6,608  !i2 

"589!66 
12,478!  63 

$77,260.77 

19,406.36 

21,585!  84 

3,386!  37 
327.66 

'3,933!  29 

6,147.52 

22,473.73 

$84,912.45 

16,572.64 

British  North  Bor- 
neo   

British  Solomon  Is- 
lands (survey) .  .  . 
Ceylon 

30*  346!  66 

3,981.58 

China 

Egypt 

Fiji 

5,776.92 

4,074.84 
7,409.69 
6,458.57 
10,298.21 
2,073.40 

Java  (survey) 

India  (survey) 

Mauritius  (survey) 
Papua  and  Queens- 
land   

Seychelles  Islands .  . 
Siam 

Administration 

Miscellaneous: 

Research     in     Life 
History  of  Hook- 
worm   Eggs    and 
Larvae 

Study  of  Methods  of 
Diagnosing  Hook- 
worm Disease. .  . . 

Conferences,  Health 
Officers  of  South- 
ern States 

Motion  Picture  Film 
on        Hookworm 
Disease 

2,073.40 

Lecture  Charts 

Salvador,     Portable 

House  and  Office . 
Salvador,  Loss  from 

Earthquake 

Thymol 

Dutch  Guiana,  Care 
and     Storage     of 
Motor  Boat  and 
SuppUes 

INTERNATIONAL    HEALTH    BOARD  235 

Years  1^13-1^14  to  1921,  Inclusive,  Covering  All  Activities — Cont'd 


1918 

1919 

1920 

1921 

Total 

$97,932.47 

$80,014.39 

$113,472.55 

$121,805.46 

$632,117.94 

:::::::: 

15,902  [95 

35,4i7!4i 

39,9i2;29 

51,483.31 
91,232.65 

3,106.23 

7,440.10 

10,546.33 

36,641  [44 

32,497;  87 

33,779!  28 

1,378.85 
23,689.34 

1,378.85 
180,006.84 

12,400.87 
5,579!  84 

12,187.58 

"498164 

28,570.03 

26,074.78 

15,241.77 

327.66 



7,8i6.66 

12,496.30 

20,306.30 

5,688.56 

5,688.66 

18,633.50 
8,089.06 

13,042.15 
4,145.61 
4,359.97 

8,29i;96 

7,514.66 

3,619.43 

520.14 

4, 643! 03 

15,850.03 

7,178.01 

5,381.44 

/ 

18,429  lis 

17,960.76 

6,066.57 

3,618.83 

22,708.34 
32,956.03 
67,442.11 
78,154.38 
33,877.73 

3,618.83 

43.95 



600.00 

643.96 

2,990.76 

2,488.71 

7,652.87 

***i7;46 

2,817.73 

1,684.74 

4,402.47 
17.40 

946.35 

476.19 

75.00 

1,496.54 

406.46 

363.00 

406.46 
15,476.21 

363.00 

236  THE   ROCKEFELLER   FOUNDATION 

TABLE  2 :  Expenditures  of  the  International  Health  Board  for  the 


Activity,  State,  and 
Country 

July  1,  1913 
Dec.31,1914 

1915 

1916 

1917 

County  Health  Work^ 
Alabama 

$ 



$ 







$ 

$182.95 

Florida 

Georgia 

Kansas 

Kentucky 

Louisiana 

Maryland 

182  95 

Mississippi 

Missouri 

New  Mexico 

North  Carolina .... 
South  Carolina 

Tennessee 

;:::;:;: 

Texas 

Virginia 

West  Virginia 

Administration 

Malaria  Control 

Southern  States: 

Alabama 

Arkansas 

Georgia 

Louisiana 

Mississippi.  .  .  . 
Missouri 

North  Carolina 
South  Carolina 

Tennessee 

Texas 

Virginia 

Administration 

Foreign  Countries: 

Ecuador 

Argentina 

Brazil 

Nicaragua 

Porto  Rico .... 

Miscellaneous: 

Conference  of 
Malaria 
Workers 



54,496.97 

n,i64!58 

43,392!  39 

39,978.58 

4,276!  23 
35,762!  35 

1  In  September,  1917,  the  hookworm  work  in  the  Southern  States  began  to  be  absorbed  in  the 
being  longer  in  some  states  than  in  others,  it  was  not  possible  to  announce  until  the  end  of  1920 
regular  functions,  responsibihty  for  all  efforts  directed  toward  tha  relief  and  control  of  hookworm 


INTERNATIONAL    HEALTH    BOARD  237 

Years  igi^-iQi4  to  iQ2i,  Inclusive,  Covering  All  Activities — Cont^d 


1918 

1919 

1920 

1921 

Total 

$2,494.53 
2,494.53 

$2,439.25 
2,264.25 

**i75.'66 

$8,182.77 

'4,494  .'66 

"957.64 
'2,73i.'73 

$167,765.19 

18,231.35 

237.75 

4,338.17 

6,316.99 

16,316.41 
5,618.28 

1,762.59 
15,652.72 
600.00 
10,837.52 
14,413.38 
17,651.97 

14,686.42 
12,765.65 
13,972.74 
4,164.56 
10,198.70 

$181,064.69 

18,231.35 
237.75 

4,338.17 
10,810.99 
16,316.41 

5,618.28 

6,704.32 
15,652.72 
600.00 
11,794.56 
14,413.38 
17,651.97 

14,686.42 
12,765.64 
13,972.74 
7,071.29 
10,198.70 

26,489.29 

4,749.02 

2'l',746.'27 

34,965.08 

13,505  .'66 
2l',i67!37 

"292;65 

133,929.02 

8,906.92 

7,048.90 

1,230.86 

30,699.94 

27,537.43 

7,526.13 
13,942.74 

1,969.94 
11,472.34 

5,284.84 

6,032.20 

4,595.59 

"425.'66 
5,445.18 

1,810.35 

150,551.39 

7,650.06 
4,777.15 

22,929!  88 

21,185.61 

1,471.37 

18,676.30 
13,321.90 
1,512.56 
10,347.23 
831.65 
10,198.68 

*5,66i!62 

'6,662!  si 

24,914.84 
245.00 

440,410.33 

16,556.98 
45,461.54 

1,230.86 

53,629.82 

170,725.42 

1,471.37 

26,202.43 
27,264.64 

3,482.50 
21,819.57 

6,116.49 
16,230.88 

4,595.59 

5,661.02 

292.05 

7,088.17 

30,360.02 

2,055.35 

programs  of  the  rapidly  developing  county  departments  of  health.  The  period  of  transition 
that  in  all  the  states  the  county  health  departments  would  henceforth  assume  as  one  of  their 
and  other  9oil-borne  diseases. 


238  THE  ROCKEFELLER  FOUNDATION 

TABLE  2:  Expenditures  of  the  International  Health  Board  for  the 


Activity,  State,  and 
Country 

July  1,  1913 
Dec.  31, 1914 

1915 

1916 

1917 

Malaria        Control — 
Continued 

Miscellaneous — ConVd 
Study  of  Source 
of    Blood 
Meals  of 
Anopheles 
Mosquitoes.  . 

$ 

$ 

$ 

$ 

Yellow  Fever  Control 
Yellow  Fever  Com- 
mission   

41,863.17 

41,863.17 

9,344.03 

7,727.74 
1,616.29 

East  Coast  of  Brazil 
and  Caribbean. . . 
Brazil      

Ecuador 

Guatemala 

Mexico  and  Central 

America 

Peru 

Salvador 

Epidemic  Work 

Tuberculosis  in 
France          



51.856.24 

Inauguration  of 
Work 

18,671.74 

Department  of  Or- 
ganization  

Public  Health  Divi- 
sion    .        .... 

Central  Administra- 
tion   

18,292.10 

Educational  Divi- 
sion   

5,316.39 

Medical  Division . . . 
Contingent  Fund. .  . 

9,576.01 

Public  Health  Educa- 
tion 



9,256.74 


12,376.63 

Department  of  Hy- 
giene, Sao  Paulo  . 

Institute  of  Hygiene, 
Czechoslova.kia. . . 

Public    Health    In- 
stitutes   

179.59 

Fellowships 

Adviser  in  Medical 
Education 

971.85 
11,225.19 

INTERNATIONAL    HEALTH    BOARD  239 

Years  IQIJ-IQ14  to  IQ21,  Inclusive,  Covering  All  Activities — Cont'd 


1918 

1919 

1920 

1921 

Total 

$ 

« 

$ 

$165.63 

$165.63 

46,639.17 

94,526.42 

139,757.40 

239,057.53 

571,187.72 

44,271.12 

83,717.13 



177,579.16 

2,897.97 

"ieiiso 

4,514.26 
461.30 

29,473.98 
14,267.22 

48,396.77 
967.82 

28,574.98 

1,698.06 

108,143.79 
15,235.04 



'*896!7i 


3*  926!  26 
23,539.03 

156,562.54 
80,335.63 

156,562.54 

80,335.63 

4,816.97 

23,539.03 

433,030.43 

602,775.78 

518,013.51 

359,540.31 

1,965,216.27 

18,671.74 

139,364.76 

47,281.28 

186,646.04 





76,191.46 

101,473.08 

177,664.54 

80,037.65 

72,394.12 

86,310.57 

89,575.04 

346,609.48 

85,755.19 
267,237.59 

141,053.34 
389,328.32 

135,920.64 
80,226.08 

79,839.90 

40,621.01 

750.00 

447,885.46 

786,989.01 

750.00 

36,642.82 

38,367.71 

68,373.54 

89,094.44 

254,111.88 

32,788.84 

23,582.57 

29,929.01 

24,727.16 

204.51 

3,466.64 

111,207.17 

204.51 

3,466.64 

2,353.98 

13,118.47 

38,409.84 

60,696.13 

115,550.27 

1,600.00 

1,666.67 



14,391.86 

240  THE   ROCKEFELLER  FOUNDATION 

TABLE  2 :  Expenditures  of  the  International  Health  Board  for  the 


Activity,  State,  and 
Country 

July  1,  1913 
Dec.31,1914 

1915 

1916 

1917 

Public  Health  Educa- 
tion— Continued 
Medical  Commission 

to  Brazil  * 

Study  of  Teaching  of 
Hygiene  and  Pub- 
lic Health  in  Med- 
ical Schools 

$ 

$ 

$9,256.74 

% 

Public  Health  Labora- 
tory Service 

United  States: 

Kansas 

Foreign: 

Guatemala .... 

Nicaragua 

Salvador 

Administration 









Miscellaneous 

Czechoslovakia  Pub- 
lic Health  Work . . 

Paris  Conference  on 
International  No- 
menclature   of 
Causes  of  Death. 

Compilation  of  Min- 
ing Sanitary  Code 

Survey  Public 
Health    Adminis- 
tration in  Massa- 
chusetts   

Investigation    of 
Powdered  Milk  . . 

Medical  Commission 
to  Brazil^ 

Visit    of    Brazilian 
Scientists  to 
United  States. .  .  . 

British    Advisory 
Committee 

Field    Equipment 
and  Supplies 

Surveys  and  Exhibits 

Pamphlets    and 
Charts     

15,138.35 

2,561.36 

742.88 
11,421.16 

847.86 
1,844.12 

-(2,279.03) 

15,057.65 

15,057!  65 

27,628.35 

9,256.73 
18,37i!62 

18,191.76 

2,464.68 
13,854.57 

1,335.66 

Library 

Express,    Freight, 
and  Exchange 

Refunds  which  could 
not    be    credited 
direct  to  budget  . 

536.85 

Represents  one  half  total  expenditure. 


INTERNATIONAL    HEALTH    BOARD  24 1 

Years  iqi^-iqi4  to  iQ2i,  Inclusive,  Covering  All  Activities — Confd 


1918 

1919 

1920 

1921 

Total 

$ 

$ 

$ 

34.69 

$ 

$9,256.74 
34.69 



16,109.70 

16,109.70 



2,539.88 

2,539.88 

307.50 

85.18 
984.34 

307.50 

85.18 

984.34 



12,192.80 

12,192.80 

23,034.17 

46,901.63 

51,248.30 

59,652.90 

256,853.11 

12,708.81 

20,736.31 

33,445.12 

615.30 

125.98 

615.30 
125.98 

26.09 

1,467.27 
500.00 



1,493.36 

500.00 

9,256.73 



7,660.12 

7,660.12 
2,561.36 

3,000.00 
14,970.85 

23,434.94 
16,870.71 

5,996.96 
23,528.78 

4,982.25 
13,437.76 

40,621.71 
127,513.10 

3,999.49 

5,499.50 

5,873.33 

10,153.44 

27,709.28 
1,844.12 

1,063.83 

1,070.39 

557.85 

2,557.04 

5,785.96 

-(2,279.03) 

CHINA  MEDICAL  BOARD 
Report  of  the  Director 


To  the  President  of  the  Rockefeller  Foundation: 

Sir: 

I  have  the  honor  to  submit  herewith  my  re- 
port as  Director  of  the  China  Medical  Board 
for  the  period  of  January  1,  1921,  to  December 
31,  1921. 

Respectfully  yours, 

ROGER  S.  GREENE, 

Director. 


245 


CHINA  MEDICAL  BOARD 

The  year  1921,  the  seventh  of  the  Board's 
work  in  China,  was  marked  by  the  completion  of 
the  main  buildings  of  the  Peking  Union  Medical 
College  and  the  occupation  of  the  hospital  and 
medical  school  by  a  nearly  complete  staff  in  all 
the  major  departments,  with  three  classes  under 
instruction  in  the  medical  school  proper.  This 
is  the  only  institution  for  which  the  China 
Medical  Board  has  thus  far  assumed  complete 
financial  responsibility.  It  is  hoped  that  it  may 
serve  as  a  model  for  other  medical  schools,  not  in 
the  sense  that  it  necessarily  represents  the  ideal 
in  all  matters  of  organization  and  construction, 
nor  that  it  is  as  yet  complete  in  every  respect  as  a 
few  of  the  largest  institutions  in  other  countries 
may  be  said  to  be  complete,  but  that  it  presents, 
in  China,  a  demonstration  more  nearly  adequate 
than  any  that  has  preceded  it,  of  the  essential 
elements  of  a  modern  medical  school. 

The  College  seeks  to  point  the  way  by  which 
the  future  system  of  Chinese  medical  education 
may  be  adapted  as  well  as  possible  to  the  actual 
conditions  in  the  country.  If  the  hopes  of  its 
founders  are  realized,  it  will  graduate  a  select 
group  of  leaders  in  medical  education,  in  research, 

247 


248      THE  ROCKEFELLER  FOUNDATION 

and  in  public  health  administration,  and  a  larger 
number  of  useful  practitioners  of  medicine  and 
surgery.  In  addition  it  will  offer  to  men  and 
women  who  have  graduated  from  other  schools, 
further  training  and  experience  to  fit  them  for 
posts  of  greater  responsibility  in  Peking  or  else- 
where. Organizations  engaged  in  the  great  work 
of  medical  education  in  China  may  be  interested 
in  watching  the  progress  of  the  school,  and  in 
observing,  with  profit  to  themselves,  those 
features  of  its  work  which  experience  shows  to 
have  been  wisely  or  unwisely  adopted. 

In  general  the  other  activities  of  the  Board 
were  of  much  the  same  nature  as  in  previous 
years.  Aid  was  continued  toward  the  current 
expenses  of  three  medical  schools  wholly  or 
partly  under  mission  control,  and  a  new  depar- 
ture was  made  in  a  grant  to  one  purely  Chinese 
school  of  funds  with  which  to  purchase  a  site  for  a 
contemplated  new  plant.  In  the  field  of  pre- 
medical  education,  contributions  were  continued 
to  four  colleges,  and  plans  were  prepared  for 
some  extension  of  this  work  so  that  the  supply  of 
prospective  medical  students  might  be  increased 
and  the  medical  schools  be  relieved  of  the  neces- 
sity of  maintaining  preparatory  departments  of 
their  own. 

A  few  new  appropriations  were  made  to  mis- 
sion hospitals  to  make  possible  necessary  im- 


CHINA  MEDICAL  BOARD  249 

provements  in  staff  and  equipment,  but  the  ex- 
perience of  the  past  few  years  seems  to  indicate 
that  the  most  effective  way  to  aid  the  hospitals  is 
to  improve  and  extend  the  facilities  in  China  for 
the  training  of  doctors,  nurses,  and  technical 
workers  of  various  kinds  who  cannot  now  be 
found  in  adequate  numbers,  in  China  or  abroad, 
even  when  the  funds  for  their  support  are  avail- 
able. It  is  therefore  likely  that  in  aiding  indi- 
vidual hospitals  in  future,  chief  consideration  will 
be  given  to  those  strategically  located  institu- 
tions which  can  be  made  to  play  an  important 
part  in  the  educational  program  by  providing  for 
the  post-graduate  training  of  doctors  and  by 
maintaining  schools  for  nurses.  In  such  centers 
there  are  large  possibilities  for  local  support  once 
the  professional  work  is  placed  on  a  high  level, 
especially  when  properly  qualified  Chinese  can  be 
found  to  share  both  in  the  professional  work  and 
in  the  administrative  control  of  the  hospital. 

Contributions  were  made  to  both  Chinese  and 
foreign  medical  associations  for  the  support  of 
the  important  work  which  they  are  doing  in  the 
preparation  of  a  unified  medical  terminology  in 
co-operation  with  other  learned  bodies,  and  in  the 
translation  of  medical  literature;  and,  finally,  the 
system  of  fellowships  and  scholarships  for  doc- 
tors and  nurses,  both  Chinese  and  foreign,  was 
continued.  But  with  the  opening,  to  graduate. 
10 


250       THE  ROCKEFELLER  FOUNDATION 

Students,  of  the  Peking  Union  Medical  College,  a 
larger  proportion  of  the  appointments  were  for 
work  at  Peking  than  abroad.  Hereafter,  the 
fellowships  for  Chinese  will  be  assigned  mainly  to 
the  Peking  School,  only  the  more  advanced 
graduate  students  who  have  shown  special  prom- 
ise in  actual  work  in  China  being  sent  abroad. 
Foreign  physicians  also  will  be  welcomed  as 
graduate  students  at  Peking,  and  it  is  hoped  that 
they  will  make  constantly  larger  use  of  the  facili- 
ties there;  but,  since  they  have  more  leisure  for 
study  during  their  periodical  furloughs  in  Europe 
and  America,  it  is  probable  that  provision  will 
continue  to  be  made  for  a  limited  number  of  fel- 
lowships and  other  grants  in  aid  of  their  study 
abroad. 

The  results  obtained  from  the  fellowships  have 
been  very  gratifying.  Nearly  all  the  Chinese 
medical  students  aided  are  now  usefully  employed 
in  their  own  country,  most  of  them  in  connection 
with  medical  schools,  a  few  in  government  serv- 
ice, and  some  in  hospitals,  Chinese  or  foreign. 
So  far  as  is  known,  only  one  is  engaged  exclusively 
in  private  practice,  and  nearly  all  are  giving  their 
time  wholly  to  institutional  work. 

Looking  back  over  the  past  ten  years,  it  is  clear 
that  medicine  in  China  has  made  real  progress. 
The  increased  effectiveness  of  medical  schools 
and  hospitals,   the  development  of  an   active 


CHINA  MEDICAL  BOARD  2^1 

Chinese  medical  association  under  enlightened 
leadership,  and  the  growing  interest  of  the 
Chinese  people  in  Western  medicine  and  public 
health,  are  sources  of  satisfaction  to  those  who 
hope  to  see  the  Chinese  people  in  possession  of  a 
scientific,  well-rounded,  and  complete  system  of 
medicine. 


I.    MEDICAL  EDUCATION 
A.  The  Peking  Union  Medical  College 

In  the  promotion  of  modern  medicine  in  a  new 
field  such  as  China,  the  matter  of  personnel  is 
naturally  the  most  important  factor,  for  when  the 
need  is  recognized  and  qualified  doctors  and 
nurses  are  available,  the  means  can  eventually  be 
found  to  maintain  them  and  to  secure  the  physi- 
cal equipment  which  they  need  to  make  their 
work  productive.  It  is  obvious  that  foreigners 
can  play  only  a  very  limited  part  so  far  as  giving 
actual  medical  service  is  concerned;  while  foreign- 
trained  Chinese  doctors  and  nurses,  though  they 
can  be  very  useful  in  the  initial  stages,  will  al- 
ways be  few  in  number  and  at  some  disadvantage 
because  the  schools  they  have  attended  have  not 
sought  to  equip  them  for  meeting  the  special 
conditions,  whether  of  climate  or  of  social  and 
economic  organization,  which  prevail  in  China. 
Therefore  the  establishment  of  an  institution  to 
provide  the  requisite  training  on  local  soil  was 
logically  the  first  step  in  the  program  of  the 
China  Medical  Board.  The  efforts  of  its  of- 
ficers during  these  first  years  have  accordingly 
been  largely  devoted  to  the  reorganization  and 
equipment,  on  a  satisfactory  basis,  of  one  such 

252 


CHINA  MEDICAL  BOARD  253 

medical  school,  the  Peking  Union  Medical  Col- 
lege. 

The  College  was  fortunate  in  securing  among 
the  first  members  of  the  new  board  of  trustees 
which  was  organized  in  1916,  Dr.  William  H. 
Welch,  of  Johns  Hopkins  University,  and  Dr. 
Simon  Flexner,  director  of  the  laboratories  of 
the  Rockefeller  Institute  for  Medical  Research. 
Experience  in  the  conduct  of  medical  and  general 
educational  work  in  China  has  been  contributed 
by  representatives  of  the  six  British  and  Ameri- 
can missionary  societies  which  had  maintained 
the  old  Union  Medical  College  from  which  the 
new  institution  has  been  developed.  All  of  the 
thirteen  trustees  have  spent  some  time  in  China 
and  have  first-hand  knowledge  of  the  problems  to 
be  met. 

Since  19 IS  the  College  has  been  supported  by 
annual  contributions  from  the  China  Medical 
Board.  The  budget  for  the  academic  year  1921- 
1922  provides  for  a  gross  expenditure,  on  the 
school  and  hospital,  of  31,418,989  Chinese  silver 
currency.  The  local  income  from  fees  and  hospi- 
tal earnings  is  estimated  at  3219,383  Chinese 
currency.  To  cover  the  diff"erence  an  appropria- 
tion of  3600,000  United  States  currency  has  been 
provided. 

The  finding  of  a  quaHfied  stafi"  and  the  organi- 
zation of  the  medical  and  pre-medical  schools 


254       THE  ROCKEFELLER  FOUNDATION 

and  the  hospital  was  entrusted  to  Dr.  Franklin 
C.  McLean,  the  professor  of  medicine  and  the 
first  Director  of  the  College.  Dr.  McLean  hav- 
ing resigned  the  directorship  in  1920  to  devote 
himself  entirely  to  the  department  of  medicine, 
Dr.  Henry  S.  Houghton,  formerly  dean  of  the 
Harvard  Medical  School  of  China,  was  elected  to 
succeed  him  and  was  formally  inaugurated  in 
September,  192  L  No  teaching  responsibilities 
are  now  attached  to  the  directorship,  since  it  has 
become  evident  that  the  administrative  duties  of 
the  post  are  so  heavy  as  to  require  the  full  time  of 
the  director. 

Dr.  Houghton  has  been  associated  with  the 
China  Medical  Board  for  the  past  six  years,  and 
has  served  as  acting  Director  of  the  Board  at  New 
York  and  as  acting  Resident  Director  in  China. 
During  the  period  of  construction  he  had  charge 
of  all  the  work  of  the  school  in  Peking.  Dr. 
Richard  M.  Pearce,  Director  of  the  Division  of 
Medical  Education  of  the  Rockefeller  Founda- 
tion, was  in  residence  in  Peking  during  the  year 
1921-1922  in  an  advisory  capacity.  In  the  ab- 
sence of  Dr.  Houghton  on  a  short  visit  to  the 
United  States  Dr.  Pearce  acted  as  Director. 

Acknowledgments  are  due  to  members  of  the 
faculties  of  many  of  the  best  American  and  British 
medical  schools  for  assistance  given  in  finding 
teachers,  and  in  affording,  to  persons  selected  for 


CHINA  MEDICAL  BOARD  257 

the  Staff,  opportunities  for  additional  prepara- 
tion in  laboratories  and  clinics. 

The  staff  of  the  medical  school  proper  at  the 
end  of  the  year  1921.  consisted  of  seven  professors, 
six  associate  professors,  one  assistant  professor, 
and  seventeen  associates,  besides  fifteen  assist- 
ants in  all  departments.  In  the  pre-medical 
school  there  were  four  assistant  professors,  five 
instructors,  and  seven  assistants.  Of  this  teach- 
ing staff,  forty-seven  were  Americans  or  Euro- 
peans and  forty-three  were  Chinese,  the  latter 
being  for  the  most  part  men  who  had  studied 
either  in  the  United  States  or  Great  Britain. 
The  higher  administrative  staff  consists  of  the 
Director,  the  superintendent  of  the  hospital,  the 
comptroller,  and  forty-seven  other  administrative 
and  technical  employes,  of  whom  forty-four  are 
Europeans  or  Americans  and  three  Chinese. 
The  nursing  department  of  the  hospital  and  the 
nurse  training  school  include  twenty-six  Euro- 
pean or  American  nurses  and  five  Chinese  gradu- 
ate nurses  trained  in  the  United  States.  All  the 
regular  teaching  staff  are  now  on  the  full-time 
basis,  but  this  policy  may  be  modified  as  the 
number  of  Chinese  physicians  and  surgeons  in 
Peking  who  would  be  qualified  to  assist  in  the 
teaching  increases. 

In  order  to  lessen  the  isolation  of  the  staff  from 
scientific  progress  in  the  West,  provision  has  been 


258       THE  ROCKEFELLER  FOUNDATION 

made  for  visiting  professorships  under  which, 
every  year,  one  or  two  leading  medical  scientists 
of  the  United  States  or  Europe  are  invited  to 
spend  from  four  months  to  ayear  at  Peking.  In 
1921  such  visiting  professorships  were  held  by  Dr. 
A.  B.  Macallum  of  McGill  University,  in  physi- 
ology, and  by  Dr.  Francis  W.  Peabody  of  Harvard 
University,  in  medicine.  Dr.  R.  B.  Seem,  the 
superintendent  of  the  new  hospital  for  the 
University  of  Chicago,  has  served  for  a  year  as 
superintendent,  aiding  in  the  organization  of  the 
hospital.  The  friendly  interest  of  such  men, 
continued  even  after  their  return  home,  has  been 
of  great  value  to  the  College. 

In  recent  years  the  number  of  foreign  travelers 
visiting  Peking  has  much  increased,  and  among 
them  are  occasionally  men  of  scientific  eminence 
whose  visits  have  proved  very  stimulating. 
More  systematic  opportunity  for  renewal  of 
contact  with  scientific  activities  at  home  is  af- 
forded by  provision  for  a  year's  leave  of  absence, 
after  four  years  of  service,  to  all  members  of  the 
medical  faculty  who  continue  with  the  College, 
full  salary  and  traveling  expenses  for  the  round 
trip  being  paid.  It  is  hoped  to  insure  to  all 
members  of  the  scientific  staff  opportunities  for 
private  study  and  research  in  addition  to  their 
teaching  and  clinical  duties. 

During  these  earlier  years  problems  of  organi* 


CHINA  MEDICAL  BOARD  259 

zation  and  the  difficulty  of  finding  and  training 
the  necessary  assistants  have  naturally  absorbed 
much  of  the  energies  of  the  staff,  but  in  spite  of 
these  handicaps  a  creditable  amount  of  work  has 
already  been  done.  China  offers  a  particularly 
attractive  field  for  study  in  many  branches  of 
medical  science.  A  beginning  is  already  being 
made  in  some  promising  anthropological  studies, 
and,  with  the  co-operation  of  numerous  indi- 
viduals and  institutions  throughout  the  country, 
an  embryological  collection  has  been  started 
which  should  furnish  the  material  for  some  very 
interesting  research.  A  systematic  survey  has 
been  begun  of  the  human  and  animal  parasites  of 
China,  and  there  is  opportunity  for  the  study  of 
many  tropical  diseases  which  are  rarely  if  ever 
encountered  in  the  West.  The  full  time  of  one 
chemist  is  being  devoted  to  the  investigation  of 
Chinese  foods,  with  a  view  to  preparing  as  soon 
as  possible  the  best  hospital  diets  for  various 
conditions.  At  the  end  of  the  year  the  services 
of  this  chemist  were  lent  for  a  short  time  to  the 
Philippine  government  for  the  study  of  diets  for 
its  leper  colonies.  There  has  just  been  assembled 
the  first  volume  of  Contributions  from  the  Peking 
Union  Medical  College^  Peking,  China,  containing 
the  work  published  in  1921.  A  list  of  these 
papers  is  appended  to  this  report  (see  page  308). 
The  requirements  for  admission  to  the  medical 


260       THE  ROCKEFELLER  FOUNDATION 

school  are  equivalent  to  those  of  institutions  in 
the  United  States  prescribing  two  years  of  college 
work  in  physics,  chemistry,  and  biology  after 
completion  of  the  high  school  course,  but  as  the 
high  schools  in  China  are  still  defective,  and  since 
it  is  necessary  to  give  the  students  a  good  com- 
mand of  the  EngHsh  language,  in  which  all  the 
medical  teaching  is  done,  it  has  been  thought 
best  to  extend  the  preparatory  course  in  these 
subjects  over  three  years.  The  first  class  was  ad- 
mitted to  the  medical  school  proper  in  the  au- 
tumn of  1919,  when  the  anatomy  building  was 
finished,  and  there  were  at  the  end  of  1921  three 
classes  under  instruction,  numbering  altogether 
twenty-two  students,  eleven  in  the  first  year,  six 
in  the  second,  and  five  in  the  third.  Women  are 
admitted  on  the  same  terms  as  men,  but  only  one 
woman  had  been  enrolled  in  the  medical  school 
up  to  that  time,  though  there  were  several  women 
among  the  fifty-two  students  in  the  pre-medical 
school.  Co-education  has  thus  far  involved  no 
difficulties  either  with  the  students  or  the  public. 
Growing  recognition  of  the  importance  of  higher 
education  for  women  and  the  lack  of  money  to 
maintain  separate  schools  for  them  have  led 
many  other  institutions  to  adopt  the  same 
policy,  the  very  novelty  of  which  has  been  an 
attraction  in  the  present  state  of  Chinese  educa- 
tional thought. 


I 


CHINA  MEDICAL  BOARD  26 1 

The  smallness  of  the  classes  during  the  period 
of  organization  has  been  a  real  advantage  both 
to  the  staff  and  to  the  students.  It  has  been 
due  in  part  to  the  fact  that  the  character  of  the 
opportunities  offered  was  not  widely  known,  and 
partly  to  the  fact  that  the  entrance  requirements 
were  considerably  higher  than  those  of  other 
schools.  The  faculty  report  that  the  students 
compare  favorably  with  those  in  good  medical 
schools  in  the  United  States.  Their  command  of 
English  is  excellent,  and  they  also  have  some  read- 
ing knowledge  of  either  French  or  German.  At 
present  the  staff  and  equipment  are  planned  for  a 
maximum  of  twenty-five  students  in  each  under- 
graduate class,  and  it  is  expected  that  this  limit 
will  be  reached  in  about  five  years.  The  course 
covers  four  years  of  formal  instruction,  with  a 
fifth  year  of  service,  as  hospital  intern  or  as 
laboratory  assistant,  required  for  the  degree.  At 
present  the  College  holds  a  provisional  charter 
from  the  Regents  of  the  University  of  the  State  of 
New  York,  and  that  body  will  confer  the  degrees 
until  an  absolute  charter  has  been  granted. 

Much  importance  is  attached  also  to  graduate 
teaching,  through  which  it  is  hoped  that  the  Col- 
lege will  be  able  to  contribute  directly  to  the  rais- 
ing of  standards  in  other  schools  and  hospitals. 
Already  a  few  men  with  such  special  training  re- 
ceived at  the  Peking  Union  Medical  College  have 


262       THE  ROCKEFELLER  FOUNDATION 

been  called  to  positions  of  greater  responsibility 
in  other  institutions.  For  such  students  special 
fellowships  are  provided,  which  are  assigned  both 
to  promising  Chinese  doctors  and  to  foreign 
medical  missionaries.  In  1921  there  were  nine- 
teen Chinese  and  seventeen  foreign  doctors  hold- 
ing these  fellowships  for  varying  periods  of  time, 
some  coming  for  short  intensive  courses  in  oph- 
thalmology and  roentgenology  and  others  re- 
maining for  several  months  of  work  in  the  clinics 
and  laboratories.  The  average  length  of  stay 
was  three  months  in  the  case  of  foreign  doctors 
and  two  months  in  the  case  of  Chinese,  but  many 
of  the  latter  had  begun  their  residence  shortly  be- 
fore the  close  of  the  year,  so  that  these  figures  do 
not  represent  the  actual  length  of  the  period  of 
study  planned.  The  total  number  of  graduate 
and  special  students  in  residence  at  the  close  of 
1921,  including  junior  hospital  staff  and  assist- 
ants in  the  laboratories,  was  seventy-five,  of 
whom  fifty-six  were  Chinese  and  nineteen  for- 
eigners. The  school  and  hospital  are  therefore 
in  more  active  use  for  educational  purposes  than 
the  small  number  of  undergraduate  students 
would  indicate.  For  the  year  1922  special  grad- 
uate courses  in  ophthalmology,  general  medi- 
cine, neurology,  orthopedic  surgery,  and  roent- 
genology have  been  announced.  During  the 
summer  of  1921  the  parasitologist  of  the  school 


CHINA  MEDICAL  BOARD  263 

conducted  a  well-attended  summer  course  for 
doctors  at  Ruling,  a  resort  in  the  Yangtze  valley. 

The  College  has  a  physical  plant  somewhat 
smaller  than  those  of  the  leading  medical  schools 
of  the  West,  but  it  has  the  great  advantages  pos- 
sessed by  too  few  schools  in  the  United  States  not 
only  of  complete  control  of  its  hospital  but  also 
of  close  contact  between  the  clinical  and  pre- 
clinical departments,  which  are  all  housed  on  one 
site  with  the  buildings  connected  by  corridors. 
Thus  the  plan  of  the  buildings  recognizes  the  ac- 
cepted fact  that  the  hospital  is  actually  as  much 
a  teaching  laboratory  as  are  the  laboratories  of 
anatomy  or  physiology.  The  school  is  conveni- 
ently situated  in  the  southeast  quarter  of  the 
Tartar  city  on  a  short  street  known  as  San  Tiao 
Hutung. 

The  exteriors  of  the  new  buildings  have  been 
planned  to  harmonize  with  the  great  architec- 
tural monuments  of  Peking  so  far  as  was  per- 
mitted by  the  modern  uses  to  which  they  were  to 
be  put.  The  green-tiled  roofs  of  Chinese  design, 
with  highly  decorated  eaves;  the  porticoes  with 
their  red  columns;  and  the  marble  terraces  about 
the  school  and  hospital  courts,  are  modeled  after 
the  palaces  and  temples  of  Peking.  In  the  case 
of  the  auditorium  building  it  has  been  possible 
to  adhere  fairly  closely  to  the  classical  Chinese 
designs.     This    attempt    to    use    the    beautiful 


«     M     U     A     I 


u   r   u   N    Q 


Fig.  75. — General  plan  of  Peking  Union  Medical  College, 
§chool  buildings 


showing   location   of   college,   hospital,    and   pre-medical 


266       THE  ROCKEFELLER  FOUNDATION 

Chinese  forms  may  be  regarded  as  typifying  the 
hope  that  the  school  itself  may  in  time  become  a 
truly  Chinese  institution,  and  that  through  it 
Chinese  scientists  may  succeed  in  adapting  West- 
ern medical  science  to  the  needs  of  their  own 
country  more  effectively  than  foreigners  can  ever 
hope  to  do.  It  is  perhaps  appropriate  that  the 
dignity  of  the  once-despised  medical  profession 
and  of  the  common  people  whom  the  hospital  is 
intended  to  serve,  should  be  symbolized  by 
the  adaptation  of  palace  architecture  to  their 
uses. 

The  laboratories  of  anatomy,  physiological 
chemistry,  physiology,  and  pharmacology  are  in 
three  buildings  forming  a  court  entered  directly 
from  the  street.  The  department  of  anatomy 
occupies  a  two-story  building  forming  the  west 
side  of  the  court  and  containing  on  the  ground 
floor  a  lecture  room  seating  fifty  persons,  a  small 
museum,  offices,  and  private  laboratories.  On 
the  second  floor  are  the  dissecting  room,  a  large 
students'  laboratory  for  microscopic  anatomy, 
and  smaller  rooms  for  Individual  workers  and 
technicians.  The  basement  contains  a  large 
refrigerator  room  for  storage  of  cadavers,  tanks, 
preparation  rooms,  animal  room,  dark  room, 
shop,  and  storerooms.  More  storage  space  is 
provided  in  the  attic.  The  physiology  building 
on  the  west  side  Is  of  the  same  size,  the  ground 


CHINA  MEDICAL  BOARD  267 

floor  containing  the  students'  laboratory  for 
pharmacology,  a  lecture  room,  and  the  necessary 
offices,  small  laboratories,  and  service  rooms  for 
this  department.  The  second  floor  is  given  up  to 
physiology  offices  and  laboratories,  including  an 
operating  suite.  In  the  basement  are  a  small 
machine  shop,  rooms  for  animals,  storerooms, 
and  a  workshop  with  dark  room  for  the  X-ray 
department. 

A  three-story  building  on  the  north  side  of  the 
court  has  on  the  ground  floor  the  administrative 
offices  of  the  College,  and  the  library  and  reading 
rooms.  The  second  floor  contains  the  labora- 
tories and  lecture  room  for  physiological  chem- 
istry, a  centrifuge  room,  and  a  small  operating 
room.  The  third  floor,  which  is  intended  for  the 
future  expansion  of  the  chemical  laboratories,  is 
now  used  as  a  dormitory  for  male  nurses.  The 
basement  contains  part  of  the  library  stacks  and 
storerooms.  Opposite  the  main  schodl  court  is 
located  an  auditorium  with  students'  reading 
rooms  and  social  rooms  attached,  which  is  the 
headquarters  of  the  department  of  religious  and 
social  work.  The  main  hall  is  used  for  chapel 
exercises,  popular  lectures,  and  entertainments 
of  various  sorts. 

North  of  the  laboratory  group  and  connected 
with  it  by  a  long  corridor,  under  which  runs  a 
tunnel    carrying    the    water,    steam,  electrical, 


268      THE  ROCKEFELLER  FOUNDATION 

compressed  air,  and  brine  lines,  is  the  hospital 
group,  with  which  is  connected  the  pathology- 
building.  The  hospital  has  an  entrance  of  its 
own  from  the  west,  with  a  smaller  court  having 
the  nurses'  home  on  the  north  and  the  hospital 
administration  building  on  the  south,  with  offices 
on  the  ground  floor  and  in  the  basement,  and 
house  officers'  quarters  on  the  second  floor.  In 
the  basement  are  also  the  mechanotherapy  and 
hydrotherapy  suites.  A  three-story  building 
facing  the  gate  contains,  on  the  ground  floor,  part 
of  the  outpatient  department  through  which  all 
public-ward  patients  enter  the  hospital.  The 
upper  floors  are  given  up  to  gynecological  and 
obstetrical  wards  and  a  small  ward  for  children. 
In  the  basement  are  bathrooms  for  newly  ad- 
mitted patients,  emergency  operating  and  dress- 
ing rooms,  and  observation  wards. 

Back  of  this  building,  and  connected  with  it  on 
three  flooirs,  is  a  large  four-story  building,  facing 
south,  the  first  floor  of  which  contains  the  con- 
sultation and  treatment  rooms  for  general  medi- 
cine and  surgery,  of  the  outpatient  department. 
Connected  with  it  in  the  basement  are  the  eye 
and  ear,  nose,  and  throat  clinics.  On  the  second 
floor  there  is  a  large  X-ray  suite,  the  clinical 
laboratories  of  the  department  of  medicine,  the 
laboratory  of  the  department  of  otolaryngology, 
a  clinical  lecture  room,  and  two  small  classrooms. 


Fig.  11 . — Graduate  students  attending  summer  course 
in  roentgenology  at  Peking  Union  Medical  College  in  1921 


Fig.  78. — Entrance  court,  from  anatomy  and  physiolog- 
ical chemistry  buildings,  Peking  Union  Medical  College 


CHINA  MEDICAL  BOARD  27 1 

The  third  floor  contains  the  offices  and  research 
laboratories  of  the  departments  of  medicine, 
surgery,  obstetrics,  and  ophthalmology.  On  the 
fourth  floor  are  the  surgical  operating  rooms,  four 
in  number,  with  the  necessary  auxiliary  rooms 
and  a  small  suite  for  dental  work.  The  main 
hospital  kitchens  and  dining  rooms  are  in  the 
basement. 

Extending  south  from  this  dispensary  and 
laboratory  building  are  the  two  main  public- 
ward  buildings,  that  for  medicine  to  the  east 
and  the  surgical  building  to  the  west.  Each 
block  has  three  floors  accommodating  twenty- 
five  patients  on  a  floor,  the  standard  unit  con- 
sisting of  one  16-bed  ward,  one  6-bed  room,  and 
three  single  rooms,  with  diet  kitchen,  dining 
room,  linen  closet,  utility  and  bathrooms.  The 
basements  of  these  buildings  provide  convenient 
space  for  storage  and  workrooms  of  different 
kinds.  Private  patients  are  accommodated  in  a 
separate  pavilion  south  of  the  administration 
building.  There  are  accommodations  here  for 
twenty  patients  on  two  floors,  and  one  floor  is  re- 
served for  quarters  for  women  members  of  the 
house  staff.  In  the  basement  are  the  kitchens 
for  the  preparation  of  European  food,  and  the 
staff  dining  rooms.  The  total  capacity  of  the 
hospital  is  250  beds,  but  on  account  of  the  small 
number  of  students  and  the  necessity  of  building 


272       THE  ROCKEFELLER  FOUNDATION 

Up  the  organization  slowly,  only  about  ISO  beds 
have  been  in  use  thus  far. 

The  department  of  pathology  is  in  a  three-story 
building  connecting  on  all  floors  with  the  medical 
clinic  and  laboratories.  In  the  basement  are  the 
autopsy  and  lecture  rooms,  the  morgue,  glass- 
washing  room,  and  storage  space.  A  one-story 
animal  house  adjoins  it.  On  the  first  floor  are 
the  laboratories  of  public  health  and  parasitol- 
ogy, a  small  museum,  the  central  pathological 
laboratory  for  all  departments  of  the  hospital, 
and  a  large  students'  laboratory  for  pathological 
histology.  The  second  floor  contains  the  offices 
and  private  laboratories  of  the  professor  of  path- 
ology and  the  associate  professor  of  bacteriology, 
the  students'  bacteriological  laboratory,  and  the 
media  room.  On  the  third  floor  are  laboratories 
intended  eventually  for  pathological  chemistry 
but  now  used  for  an  investigation  of  Chinese 
foods,  and  the  illustration  service,  including 
photographic  rooms.  A  part  of  this  floor  is  cut 
off  for  emergency  isolation  wards  for  the  hospital. 

A  one-story  building  opening  on  the  service 
court  in  the  northeastern  corner  of  the  lot  con- 
tains the  receiving  rooms  for  supplies  of  all  kinds 
for  the  hospital  and  medical  school,  and  the  large 
bedding  sterilizer.  This  connects  with  the  power 
house,  in  which  are  located  the  electric  genera- 
tors, air  compressors,  pumps  for  the  hot  and  cold 


Fig.  79. — Electrocardiograph  room  in  hospital,  Peking 
Union  Medical  College 


Fig.  80. — An  operating  room  in  hospital,  Peking  Unioa 
Medical  College 


Fig.  81. — Laboratory  of  physiological  chemistry,  Peking 
Union  Medical  College 


Fig.   82. — Dissecting  room,   anatomy  building,   Peking 
Union  Medical  College 


CHINA  MEDICAL  BOARD  275 

water,  refrigeration  plant,  et  cetera.  The  build- 
ings are  all  heated  in  winter  by  exhaust  steam 
from  the  engines.  All  the  water  used  is  pumped 
from  deep  wells  driven  on  the  college  property,  as 
the  supply  from  the  municipal  water-works  is 
inadequate  and  extremely  expensive.  Above 
the  engine  room  is  the  laundry  equipped  with 
American  machinery,  and  above  that  are  two 
floors  of  servants'  rooms.  As  the  city  of  Peking 
has  no  public  gas  plant,  and  since  modern  me- 
chanical industries  have  been  little  developed 
there,  it  has  been  necessary  for  the  College  to 
develop  a  small  industrial  area  of  its  own  across 
a  narrow  street  from  the  main  buildings.  Here 
are  located  a  small  gas  plant;  the  main  garage; 
woodworking,  metal,  and  paint  shops;  a  pre- 
cision shop;  and  a  large  storehouse  to  contain 
the  reserve  supplies  of  all  sorts,  of  which  it 
is  necessary  to  carry  a  large  stock  on  account 
of  the  remoteness  of  Peking  from  the  markets 
of  the  world. 

The  pre-medical  school  and  students'  dormi- 
tories are  in  older  buildings  on  detached  property 
nearby.  The  College  also  possesses  thirty-six 
residences  for  members  of  the  staff,  thirty-one  of 
which  have  been  newly  built  with  all  modern 
conveniences.  The  building  of  these  houses  was 
made  necessary  by  the  shortage  of  residences 
suitable  for  use  by  foreigners.     Thus  the  whole 


276       THE  ROCKEFELLER  FOUNDATION 

physical  plant  is  inevitably  much  larger  and 
more  complicated  than  would  be  necessary  for  a 
medical  school  of  the  same  size  in  any  large  city 
of  the  Western  world,  and  this  fact  adds  much  to 
the  administrative  difficulties  and  expense  of 
conducting  the  institution. 

It  will  be  noted  that  the  institution  does  not 
yet  possess  a  special  children's  clinic  nor  institutes 
for  mental  and  infectious  diseases.  Though 
children  not  suffering  from  infectious  diseases  can 
be  received  in  the  present  hospital,  the  lack  of 
suitable  provision  for  the  study  of  mental  and 
infectious  diseases  is  a  serious  defect  that  must 
eventually  be  remedied,  perhaps  by  affiliation 
with  institutions  under  Chinese  control,  of  which 
none  that  are  really  satisfactory  now  exist. 
This  solution  would  in  many  respects  be  the  most 
desirable,  as  the  maintenance  of  such  hospitals, 
besides  adding  greatly  to  the  expense,  would  in- 
volve some  embarrassing  administrative  prob- 
lems with  which  a  foreign  institution  might  find 
it  difficult  to  deal.  The  prospects  for  such  co- 
operation are  encouraging.  Already  arrange- 
ments for  the  care  of  convalescent  children  have 
been  made  with  a  Chinese  institution  in  the 
western  hills  near  Peking;  a  project  is  on  foot  for 
an  eye  hospital  with  which  the  College  depart- 
ment of  ophthalmology  would  co-operate;  and 
Dr.  S.  p.  Chen,  an  able  Chinese  physician  in 


CHINA  MEDICAL  BOARD  277 

charge  of  the  government  isolation  hospital,  is 
assisting  in  the  teaching  of  infectious  diseases. 

The  buildings  have  been  occupied  gradually 
as  they  have  been  completed.  When  the  new- 
hospital  was  finally  opened  in  July,  1921,  the 
clinical  work  was  transferred  to  it  from  the  old 
hospital  which  had  been  used  under  the  former 
organization.  The  attempt  has  been  made  to 
provide  the  faculty  with  all  the  mechanical 
equipment  needed  for  the  best  possible  work  in 
the  laboratories  and  wards.  Electric  current, 
including  separate  light  and  power  and  low- 
voltage  lines,  gas,  medium-pressure  steam,  com- 
pressed air,  hot  and  cold  water,  and  refrigeration 
have  as  far  as  possible  been  supplied  at  all  points 
where  they  were  required.  The  wards  and  the 
physiological  laboratory  have  permanent  con- 
nections with  the  electrocardiograph  in  the  medi- 
cal laboratories,  there  are  telephone  connections 
throughout  the  buildings,  and  electric  call- 
systems  have  been  installed.  Besides  standard 
apparatus  for  teaching  and  clinical  work,  a 
considerable  amount  of  special  equipment  for 
research  laboratories  has  been  provided. 

A  library  has  been  collected  containing  some 
22,000  volumes  and  450  sets  of  the  most  impor- 
tant journals.  Since  no  other  large  medical 
libraries  exist  in  China,  it  has  been  necessary  to 
make  the  collection  more  comprehensive  than  is 


278       THE  ROCKEFELLER  FOUNDATION 

customary  in  a  similar  school  in  the  United  States, 
where  access  can  be  had  to  other  libraries. 
There  are  still  some  serious  gaps,  as  might  be  ex- 
pected in  a  new  library,  but  nevertheless  a  very 
useful  working  collection  has  already  been 
formed. 

Great  importance  is  attached  to  the  training 
school  for  nurses,  conducted  in  the  hospital. 
High-school  graduation  or  its  equivalent,  and  a 
working  knowledge  of  English,  are  required  for 
admission,  and  the  regular  course  extends  over 
four  years,  including  one  preparatory  year,  during 
which  instruction  is  given  in  physics,  chemistry, 
and  biology  in  addition  to  the  special  subjects 
required  for  nurses.  By  special  arrangement, 
Peking  University  offers  a  bachelor's  degree 
to  nurses  taking  a  combined  course  in  its  arts 
college  and  the  nurse  training  school  of  the  Pe- 
king Union  Medical  College.  Special  classrooms 
and  laboratories  for  this  school  are  provided  in 
the  nurses'  home.  It  is  hoped  that  nurses  trained 
here  will  be  prepared  to  take  positions  of  re- 
sponsibility as  teachers  and  supervisors  in  other 
schools  and  hospitals.  In  1921  ten  pupils  were 
enrolled.  Only  women  are  now  admitted  to  the 
school,  but  as  the  supply  of  female  nurses  and 
pupils  is  very  small,  a  number  of  male  nurses  are 
still  employed,  under  female  supervisors,  in  the 
men's  wards. 


CHINA  MEDICAL  BOARD  279 

The  formal  opening  exercises  of  the  College 
and  the  inauguration  of  the  new  director,  Dr. 
Henry  S.  Houghton,  were  held  in  Peking  during 
the  week  extending  from  September  IS  to  22, 
1921.  Advantage  was  then  taken  of  the  pres- 
ence of  a  number  of  distinguished  guests  from  all 
over  the  world  to  hold  a  series  of  scientific  meet- 
ings and  clinics.  Meetings  of  the  trustees  were 
held  at  the  same  time,  to  discuss  import:ant 
matters  of  policy  in  the  light  of  intimate  contact 
with  the  staff  and  the  current  work  of  the  school. 
Among  the  eminent  scientists  attending  the  exer- 
cises and  taking  part  in  the  proceedings  were: 

Prof.   T.  Tuffier,   Surgeon   at   the   Hopital    de   la   Pitie, 

Paris. 
Dr.  A.  B.  Macallum,  Professor  of  Biochemistry  at  McGill 

University,  Montreal. 
Sir  William  Cecil  Smyly,  Dublin. 
Dr.  R.  T.  Leiper,   Director  of  the  Department  of  Hel- 

minthology,  London  School  of  Tropical  Medicine. 
Dr.  Francis  W.  Peabody,  Associate  Professor  of  Medicine, 

Harvard  Medical  School. 
Dr.  George  E.  de  Schweinitz,  Professor  of  Ophthalmology, 

University  of  Pennsylvania. 
Dr.  Florence  Sabin,  Professor  of  Histology,  Johns  Hopkins 

University. 
Dr.   S.   S.   Goldwater,   Director  of  Mt.   Sinai  Hospital, 

New  York  City. 
Dr.  S.  Hata,  of  the  Kitasato  Institute,  Tokyo. 
Professor  Mataro  Nagayo,  of  the  Imperial  University, 

Tokyo. 
Professor  K.  Shiga,  of  Seoul,  Korea, 


280       THE  ROCKEFELLER  FOUNDATION 

Dr.  Wu  Lien-teh,  of  the  North  Manchurian  Plague  Pre- 
vention Service. 

Dr.  S.  P.  Chen,  Medical  Superintendent  of  the  Govern- 
ment Isolation  Hospital,  Peking,  and  Medical  Director 
of  the  Central  Hospital. 

Sir  William  Brunyate,  K.  C.  M.  G.,  Vice-Chancellor  of 
the  University  of  Hong  Kong. 

Dr.  C.  W.  Wang,  University  of  Hong  Kong. 

President  Guy  Potter  Benton  of  the  University  of  the 
Philippines. 

Dr.  F.  G.  Haughwout,  Professor  of  Protozoology  and 
Parasitology,  University  of  the  Philippines. 

Dr.  A.  de  Waart,  Member  of  Commission  on  Medical 
Education,  Dutch  East  Indies,  Weltevreden,  Java. 

The  Chinese  Government  was  represented  at 
the  formal  opening  by  the  Ministers  of  Educa- 
tion, Foreign  Affairs,  and  the  Interior,  v^ho  made 
addresses  testifying  to  their  appreciation  of  the 
purposes  of  the  College  and  its  founders.  The 
Minister  of  Foreign  Affairs  paid  high  tribute  also 
to  the  work  of  British  and  American  medical 
missionaries  in   China. 

On  the  part  of  the  Chinese  public  there  has 
been  no  lack  of  appreciation  of  the  service 
rendered  by  the  hospital,  such  difficulties  as  have 
arisen  being  due  to  the  fact  that  so  many  pa- 
tients have  come  for  treatment  that  it  has  been 
necessary  to  limit  the  numbers  in  order  not  to 
interfere  with  the  teaching  and  other  duties  of 
the  staff.  In  general,  foreign  patients  are  re- 
ceived only  when  referred  by  their  physicians. 


CHINA  MEDICAL  BOARD  28 1 

These  restrictions,  though  they  have  caused 
some  misunderstanding,  are  unavoidable  if  the 
hospital  is  to  fulfil  its  primary  function  as  a  teach- 
ing institution  and  give  its  best  service  to  those 
whom  it  admits. 

Members  of  the  staff  have  frequently  been 
called  upon  for  public  service  in  emergencies. 
In  previous  years  they  have  aided  in  attending 
those  wounded  in  civil  war,  and  in  combating 
plague  and  other  epidemics.  In  1921,  members 
of  the  department  of  medicine  assisted  in  organiz- 
ing and  administering  the  sanitary  work  con- 
nected with  the  relief  of  famine  sufferers,  and  the 
director  of  religious  and  social  service  had  charge 
of  the  recruiting  of  relief  workers  from  all  over 
the  country.  Diets  for  the  famine  sufferers  were 
also  planned  in  consultation  with  the  food  chem- 
ist of  the  college.  It  is  evident,  therefore,  that 
the  College  is  now  a  going  concern,  already 
making  a  contribution  to  the  community  which 
it  may  be  hoped  will  become  more  significant  as 
time  goes  on. 

B.  Aid  to  Other  Medical  Schools 

While  it  has  been  necessary  to  provide  one 
fully  equipped  and  highly  organized  medical 
school  to  aid  in  setting  standards  for  medical 
education  in  China,  and  to  give  opportunity  for 
the  training  of  teachers  and  investigators,  it  is 


282       THE  ROCKEFELLER  FOUNDATION 

realized  that  the  general  progress  of  medicine 
must  depend  largely  on  institutions  under  other 
auspices  throughout  the  country;  and  that  in  all 
probability  many  of  the  future  leaders  of  the 
Chinese  medical  profession  will  be  men  who  have 
secured  their  undergraduate  training  entirely  in 
such  schools.  The  Board  has  therefore  been 
greatly  interested  in  the  development  of  medical 
schools  other  than  that  for  which  it  has  assumed 
complete  responsibility,  and  has  given  some 
financial  aid  to  those  which  seemed  to  offer  the 
most  promise  of  sound  growth. 

1.  Hunan- Yale  College  of  Medicine 

In  the  past,  foreign  agencies  of  various  kinds 
have  made  the  greatest  contributions  to  medical 
progress  in  China,  the  Chinese  organizations 
having  lacked  either  the  experience  or  the  as- 
surance of  continued  financial  support  that  are 
needed  for  maintaining  high-grade  medical 
schools  and  hospitals.  Nevertheless,  it  is  upon 
the  Chinese  themselves  that  the  responsibility 
for  progress  must  eventually  rest,  and  they  are 
already  able  to  make  an  important  contribution 
of  their  own,  not  only  in  forming  and  carrying  out 
policies  that  will  be  adapted  to  Chinese  condi- 
tions, but  in  securing  funds. 

In  the  present  period  of  transition  from  foreign 
to  Chinese  leadership,  it  is  fortunate  that  there 


CHINA  MEDICAL  BOARD  283 

exists,  In  the  Hunan- Yale  College  of  Medicine 
at  Changsha,  an  institution  in  which  foreigners 
and  Chinese  are  partners  on  equal  terms.  This 
school  is  controlled  jointly  by  the  Ruchun  Edu- 
cational Association,  a  society  of  Hunan  gentle- 
men which  receives  a  subsidy  from  the  provincial 
government,  and  by  the  Yale  Foreign  Missionary 
Society.  The  dean  is  a  Chinese  graduate  of 
Yale,  who  enjoys  the  full  confidence  of  both 
foreigners  and  Chinese,  and  the  staff  is  made  up 
of  Chinese  and  foreigners  in  practically  equal 
numbers  (six  Chinese  and  seven  foreigners). 
The  greatest  assets  of  this  school  are  the  interest 
of  the  Chinese  community  in  which  it  is  working, 
and  the  high  educational  ideals  of  its  American 
supporters,  resulting  from  close  relations  with  a 
great  American  university.  While  its  resources 
and  staff  have  been  very  limited,  this  disadvan- 
tage has  to  a  great  extent  been  compensated  by 
the  enthusiasm  of  its  teachers  and  students,  and 
by  the  fact  that  the  number  of  students  has  been 
so  small  that  it  has  been  possible  to  maintain 
more  intimate  contact  between  staff  and  students 
than  is  possible  in  a  larger  institution. 

The  first  class  of  eleven  men  graduated  in  1921, 
on  completion  of  the  five-year  course,  and  in  the 
fall  term  of  that  year  there  were  forty-five  stu- 
dents registered  in  the  five  classes  of  the  medical 
school.     There  is  probably  no  hospital  in  China 


284  THE  ROCKEFELLER  FOUNDATION 

where  the  interns  are  doing  better  work  than 
these  first  graduates  are  doing  in  the  Hunan- 
Yale  hospital.  Instruction  in  this  school,  as  at 
Peking,  is  given  entirely  in  English,  on  account 
of  the  lack  of  sufficient  medical  literature  in 
Chinese  and  the  difiiculty  of  securing  qualified 
teachers  who  speak  fluently  the  Chinese  tongue. 
Much  of  the  success  of  the  school  is  due  to  the 
thorough  preparation  received  by  the  pre-medical 
students  at  the  College  of  Yale-in-China .  Women 
students  are  now  admitted  on  equal  terms  with 
men. 

The  physical  plant  consists  of  a  fine  120-bed 
hospital  given  by  a  Yale  graduate,  a  medical 
school  building  erected  with  Chinese  funds,  and  a 
pre-medical  laboratory  contributed  by  the  China 
Medical  Board.  Funds  for  an  outpatient  build- 
ing to  cost  about  325,000  gold  have  been  pledged 
by  the  Commonwealth  Fund  and  the  provincial 
government.  The  budget  of  the  medical  school 
and  hospital  for  the  year  1921-1922  amounted  to 
387,000  gold.  The  China  Medical  Board  is 
making  an  annual  contribution  of  341,605  Mex. 
and  36,645  gold  to  the  hospital  and  pre-medical 
department,  of  which  about  37,000  is  assigned  to 
the  College  of  Yale-in-China  for  work  in  physics, 
chemistry,  and  biology.  For  the  1921-1922 
budget,  about  315,000  gold  will  be  available  from 
a  grant  of  the  Commonwealth  Fund.     In  normal 


CHINA  MEDICAL  BOARD  285 

years  the  school  receives  from  the  provincial 
government  ?S0,000  Mex.  (about  ?2S,000  gold) 
per  annum. 

The  school  has  been  seriously  embarrassed 
financially  during  recent  years,  on  account  of  the 
political  disturbances  in  Hunan  province,  which 
have  prevented  the  government  from  giving  its 
usual  support  to  educational  work.  The  medi- 
cal school  has  suffered  with,  but  no  more  than, 
the  government  educational  institutions  of  Hu- 
nan. While  all  praise  must  be  given  to  the  staif 
for  the  results  accomplished  under  great  dif- 
ficulties, more  support  is  urgently  needed.  The 
shortage  of  men  has  prevented  the  proper  de- 
velopment of  departmental  organization,  partic- 
ularly for  the  pre-clinical  sciences,  which  have 
been  taught  partly  by  men  with  heavy  hospital 
duties.  There  is  also  need  for  more  and  better 
qualified  assistants  in  nearly  all  departments, 
and  for  more  supplies  and  equipment.  It  is  to  be 
hoped  that  generous  aid  will  be  forthcoming  from 
the  Chinese  and  foreign  friends  of  the  institution, 
for  there  are  probably  few  schools  in  China  where 
greater  results  may  reasonably  be  expected  from 
the  expenditure  of  any  given  sum. 

2.  Shantung  Christian  University  School  of  Medicine 

The  work  of  Christian  missionary  societies  in 
giving  medical  aid  to  China  deserves  high  praise. 


286  THE  ROCKEFELLER  FOUNDATION 

Medical  education  under  missionary  auspices 
began  in  hospitals,  where  one  or  two  men  did  all 
the  teaching  in  addition  to  carrying  the  routine 
clinical  and  administrative  work.  While  some 
useful  assistants  were  thus  trained  it  was  clear 
that  no  permanently  satisfactory  results  could  be 
obtained  by  this  method,  and  consequently  there 
were  organized,  in  several  important  centers, 
medical  schools  where  a  few  men  were  set  apart 
for  teaching.  Even  in  these  schools  the  teachers 
were  far  too  few,  and  very  inadequate  attention 
was  given  to  the  fundamental  sciences.  In  1914 
there  were  thirteen  such  schools  under  mission 
auspices. 

The  Council  on  Medical  Education  of  the 
China  Medical  Missionary  Association  early  drew 
attention  to  the  desirability  of  concentrating  in  a 
few  places  the  meagre  funds  available  for  the 
maintenance  of  these  schools,  in  order  to  insure 
the  best  results;  and  after  the  China  Medical 
Board  undertook  to  support  in  Peking  a  school 
teaching  in  English,  the  Council  recommended 
that  medical  teaching  in  Chinese  be  concentrated 
so  far  as  possible  at  the  Shantung  Christian 
University  at  Tsinan.  As  a  result  of  the  growing 
appreciation  of  the  wisdom  of  this  policy,  which 
was  made  more  evident  by  the  increasing  cost  of 
medical  work  and  the  difficulty  of  securing  men 
and  money  during  the  late  war,  as  well  as  by  the 


Fig.  83. — Ward  In  Central  Hospital,  Peking.  The 
hospital,  organized  and  maintained  by  Chinese,  has  been 
aided  by  the  Foundation 


Fig.    84. — ^Nursing   demonstration   and   practice   room, 
Nurses'  Home,  Peking  Union  Medical  College 


Fig.    85. — Corridor    connecting    units    of    the    hospital 
group,  Peking  Union  Medical  College 


Fig.    86. — Surgical   ward   of   hospital   building,    Peking 
Union  Medical  College 


CHINA  MEDICAL  BOARD  289 

more  general  understanding  of  the  requirements 
of  modern  medical  science,  there  has  been  a 
marked  decrease  in  the  number  of  schools,  six 
having  been  closed  and  no  new  ones  having  been 
opened.  It  is  likely  that  plans  now  under  discus- 
sion will  result  in  still  further  reduction.  At  the 
same  time  the  medical  department  of  the  Shan- 
tung Christian  University,  to  which,  originally, 
only  two  societies  were  contributing,  is  now  of- 
ficially supported  by  eight  societies,  and  there  are 
actually  nine  missionary  organizations  contribut- 
ing to  its  maintenance. 

In  1914  the  total  budget  was  estimated  at  only 
320,000  Mex.,  and  there  were  on  the  staff  only 
five  fully  qualified  medical  teachers  and  one  nurse. 
There  was  no  administrative  staff.  In  1916 
the  China  Medical  Board  made  an  appropria- 
tion of  250,000  to  this  school,  for  new  buildings 
and  equipment,  and  a  total  of  3100,000  for 
maintenance  for  five  years,  on  condition  that  the 
school  should  undertake  the  instruction  of  five 
classes  of  students  previously  enrolled  at  Peking. 
Additional  appropriations  were  later  made  to 
cover  the  loss  by  exchange  on  these  grants.  This 
agreement  came  to  an  end  in  1921,  and  a  new  ap- 
propriation of  333,000  Mex.  was  made  for  the 
maintenance  of  the  school  during  the  year  1921- 
1922,  pending  discussion  regarding  the  future 
development  of  the  institution.     At  the  end  of 

18 


290       THE  ROCKEFELLER  FOUNDATION 

the  year  1921  the  staff  included  twenty-one 
teachers  and  administrative  officers  who  were 
either  foreigners  or  Chinese  who  had  studied 
abroad;  there  were  four  foreign  nurses;  and  the 
locally  trained  staff  had  greatly  increased  in 
efficiency.  The  budget  contemplated  for  1922- 
1923  amounts  to  ?143,180  Mex.  for  the  school 
and  hospital.  This  great  increase  in  the  total 
budget,  when  the  contribution  of  the  China  Med- 
ical Board  has  been  decreased  from  the  equivalent 
of  340,000  to  333,000  Mex.,  is  convincing  evi- 
dence of  the  enterprise  of  those  responsible  for 
the  school.  A  small  annual  grant  is  now  made 
by  the  province. 

The  preparation  of  the  students  has  been  much 
improved  by  the  arrival  of  new  teachers  of  phys- 
ics, chemistry,  and  biology,  and  excellent  labora- 
tories for  these  sciences  have  been  provided  in  the 
new  buildings  of  the  university.  The  teaching  in 
the  medical  school  has  been  entirely  reorganized. 
Men  with  special  training  in  the  pre-clinical 
sciences  have  been  set  free  to  devote  themselves 
wholly  to  this  fundamental  work,  and  the  clinical 
departments  have  also  been  strengthened.  More 
attention  has  been  devoted  to  the  teaching  of 
English,  so  that  now  the  best  students  are  able  to 
use  English  books  and  journals  and  after  gradua- 
tion can  continue  their  studies  in  institutions 
where  the  teaching  is  in  that  language.     It  is 


CHINA  MEDICAL  BOARD  29 1 

proposed  hereafter  to  admit  women  students  to 
the  school,  and  a  plan  is  under  consideration  for 
uniting  with  this  institution  the  medical  school 
for  women  now  at  Peking. 

Among  the  important  activities  of  the  school 
are  the  translation  of  medical  textbooks  into 
Chinese,  and  co-operation  with  government  in- 
stitutions and  the  National  Medical  Association 
in  working  out  a  Chinese  medical  terminology. 
A  small  journal  in  Chinese  is  also  being  published. 

3.  Medical  Education  at  Shanghai 

The  organizations  interested  in  medical  educa- 
tion under  mission  auspices  in  the  lower  Yangtze 
region  have  been  making  plans  for  a  union  insti- 
tution in  that  city,  but  no  definite  decision  had 
been  reached  up  to  the  close  of  the  year.  Mean- 
while the  Pennsylvania  Medical  School  of  St. 
John's  University  is  continuing  its  work.  The 
China  Medical  Board  has  been  contributing  to 
this  school  the  salary  of  one  man. 

4.  Co-operation  with  Chinese  Institutions 

The  National  Medical  College  at  Peking, 
which  is  controlled  by  the  Ministry  of  Education, 
is  one  of  the  most  promising  schools  under  purely 
Chinese  control.  This  institution  is  contemplat- 
ing the  construction  of  a  new  plant.  Last  year 
an  advantageous  site  became  available,  toward 


292       THE  ROCKEFELLER  FOUNDATION 

the  purchase  of  which  the  China  Medical  Board 
made  a  grant  of  36,000.  The  old  site  having 
greatly  increased  in  value  on  account  of  busi- 
ness development  in  its  vicinity,  the  authorities 
propose  to  sell  it  and  to  apply  the  proceeds 
toward  the  erection  of  a  modern  school  and 
hospital. 

In  general  the  government  schools  have  suf- 
fered during  recent  years  on  account  of  the  dif- 
ficult political  and  financial  conditions  in  the 
country,  but  several  of  their  leading  teachers 
have  been  sent  abroad  for  further  study  in 
preparation  for  the  development  which  is  sure 
to  follow  any  improvement  in  the  present  situa- 
tion. 

There  are  other  important  medical  schools  in 
China  with  which  the  China  Medical  Board  has 
had  no  relations  other  than  those  of  friendly  in- 
tercourse. Of  these  the  best  organized  are  the 
South  Manchuria  Medical  College  at  Mukden, 
which  is  supported  by  the  South  Manchuria  Rail- 
way Company,  and  the  former  German  Medical 
School  at  Shanghai,  which  is  now  supported 
largely  with  Chinese  funds.  The  medical  school 
of  the  University  of  Hong  Kong,  though  outside 
of  Chinese  jurisdiction,  is  also  making  an  im- 
portant contribution  to  medical  education  in 
China.  It  will  have  wide  influence  in  the  regions 
to  the  south,  particularly  the  British  East  Indies 


CHINA  MEDICAL  BOARD  293 

and  the  Straits  Settlements.  The  China  Medical 
Board  has  contributed  toward  two  scholarships 
in  each  class  of  this  school  for  students  from  the 
Canton  Christian  College,  the  first  to  become 
available  for  the  class  of  1922. 


II.  PRE-MEDICAL  EDUCATION 

As  the  work  of  the  China  Medical  Board  has 
progressed,  it  has  become  evident  that  no  general 
improvement  in  medical  education  could  be  ex- 
pected until  well-prepared  students  were  avail- 
able in  much  larger  numbers  than  at  present. 
Hitherto  the  main  effort  of  the  Board  in  the  field 
of  pre-medical  education  has  been  made  in  con- 
nection with  the  Peking  Union  Medical  College, 
where  the  pre-medical  school  has  served  not  only 
to  prepare  students  for  study  at  Peking,  but  also 
to  set  a  standard  for  other  institutions.  In  1921 
a  few  teaching  fellows  were  admitted  to  the  school 
in  order  that  they  might  have  the  experience  of 
teaching  in  a  well-equipped  school,  under  the 
guidance  of  experienced  instructors,  while  at  the 
same  time  carrying  on  studies  of  their  own.  It  is 
hoped  that  these  men  will  later  become  useful 
members  of  the  faculties  of  other  institutions. 

At  the  meeting  of  the  trustees  of  the  College, 
at  Peking  in  September,  1921,  it  was  decided  to 
look  forward  to  the  closing  of  the  pre-medical 
school  as  soon  as  a  sufficient  number  of  properly 
prepared  students  could  be  secured  from  other 
colleges.  As  conditions  now  stand,  considerable 
improvement  must  be  made  in  the  schools  and 

294 


CHINA  MEDICAL  BOARD  295 

colleges  of  China  before  such  action  will  be 
feasible.  Mention  has  been  made  in  the  reports 
for  previous  years  of  grants  in  aid  of  the  pre- 
medical  work  at  St.  John's  University  at  Shang- 
hai; the  Hunan- Yale  Medical  College,  Changsha; 
Ginling  College  for  Women,  Nanking;  Fukien 
Christian  University,  Foochow;  and  Canton 
Christian  College.  Buildings  have  now  been 
erected  with  these  grants  at  Shanghai  and 
Changsha,  and  additional  teachers  have  been 
secured. 

For  several  years  the  leading  missionary  socie- 
ties have  felt  that  it  was  necessary  to  have  ex- 
perts make  a  careful  study  of  the  whole  field  of 
Christian  education  in  China  with  a  view  to  in- 
creasing its  effectiveness.  Last  year  it  became 
possible  to  secure  an  exceptionally  well-qualified 
international  commission  to  make  this  study. 
As  it  seemed  to  the  China  Medical  Board  that 
the  work  of  the  Commission  was  likely  to  add 
much  to  the  effectiveness  of  its  own  medical 
program,  a  contribution  of  ?8,000  was  made 
toward  the  expenses  of  the  undertaking.  The 
investigations  of  the  Commission  were  carried 
out  in  the  fall  of  1921,  but  its  report  has  not  yet 
been  published.  A  special  investigation  of  pre- 
medical  education  in  Chinese  and  foreign  col- 
leges was  also  made  for  the  Board  in  1921  by  Dr. 
Paul  Monroe,  of  Teachers  College,  New  York, 


296       THE  ROCKEFELLER  FOUNDATION 

and  by  Dr.  W.  W.  Stifler  and  Dr.  S.  D.  Wilson, 
of  the  pre-medical  school  of  the  Peking  Union 
Medical  College.  At  about  the  same  time  lead- 
ing Chinese  educators,  as  a  result  of  a  prelimi- 
nary survey  made  for  them  by  Dr.  Monroe, 
organized  a  National  Educational  Reform  As- 
sociation which  is  proposing  to  employ  Chinese 
and  foreign  experts  to  suggest  means  of  improv- 
ing the  strictly  Chinese  schools.  Great  improve- 
ments in  general  education  may  be  expected  as  a 
result  of  these  studies,  and  the  medical  schools 
will  also  profit  from  them. 


III.    OTHER  ACTIVITIES 
A.  Aid  to  Hospitals 

In  practically  all  countries  it  is  recognized  that 
even  those  hospitals  which  are  not  connected  with 
medical  schools  have  important  educational  func- 
tions to  perform.  This  is  particularly  true  of  the 
hospitals  in  China.  Besides  training  interns 
and  nurses  they  provide  opportunities  for  the 
continued  employment  of  young  doctors  who 
need  the  facilities  of  the  hospital  and  the  friendly 
guidance  of  more  experienced  men  if  they  are  to 
continue  their  professional  growth.  Local  med- 
ical associations  in  China  have  been  little  de- 
veloped; there  are  no  medical  libraries  except 
in  the  schools;  and  outside  of  a  few  large  cities 
there  is  no  systematic  provision  for  stimulating 
professional  intercourse  between  practicing  phy- 
•  sicians.  Association  with  a  good  hospital  can  do 
much  to  compensate  for  these  disadvantages, 
and  thus  conserve  for  future  usefulness  the  men 
turned  out  by  the  schools. 

The  hospital  has  also  a  useful  part  to  play  in 
the  education  of  the  public.  In  many  cities  the 
mission  hospital  is  the  only  place  where  modern 
medicine  is  practiced,  and  the  only  center  for 
popular  health  education.     In  time  of  epidemic, 

297 


298       THE  ROCKEFELLER  FOUNDATION 

famine,  or  civil  war,  it  is  to  the  hospital  that  the 
people  and  the  officials  look  for  medical  and  sur- 
gical aid  and  for  advice  as  to  preventive  measures 
against  disease.  As  a  result  of  the  work  that 
these  often-isolated  institutions  have  done,  there 
is,  on  the  part  of  the  people,  a  widespread  con- 
fidence in  Western  medicine  and  a  growing  ap- 
preciation of  the  importance  of  public  health 
measures,  one  indication  of  which  is  the  popular- 
ity of  the  newly-coined  word,  wei-sheng  ("life- 
protecting,"  or  "sanitary")?  which  is  now  fre- 
quently seen  even  on  the  signs  of  laundries  and 
barber-shops.  In  certain  cities,  the  local  authori- 
ties pay  large  annual  subsidies  to  mission  hospi- 
tals in  recognition  of  their  public  service,  and 
gifts  for  special  purposes  are  common. 

Since  the  China  Medical  Board  began  its  work 
in  1915,  grants  have  been  made  to  mission  hospi- 
tals to  enable  them  to  improve  their  work, 
through  additions  to  plant  and  equipment  or 
through  increases  of  staff  and  maintenance  ap- 
propriations. In  1921  payments  were  made  to 
sixteen  such  institutions  to  the  total  amount  of 
3123,985.89.  It  is  the  usual  rule  at  present  to 
contribute  not  more  than  one  half  of  the  amount 
required  for  the  proposed  improvements.  In  this 
way  the  interest  of  other  friends  of  the  hospital  is 
stimulated  and  a  broader  foundation  is  laid  for 
future  development.     New  appropriations  were 


CHINA  MEDICAL  BOARD  299 

made  last  year  to  five  institutions:  the  Methodist 
Hospital  in  Peking,  for  the  development  of  its 
dental  department;  the  American  Board  Hospital 
in  Fenchow,  Shansi,  for  the  completion  of  its 
excellent  new  hospital  and  for  more  adequate 
maintenance;  the  Southern  Baptist  Hospital  at 
Yangchow,  Kiangsu,  and  the  Canton  Hospital, 
for  maintenance;  and  the  American  Presbyterian 
Hospital  at  Chefoo,  Shantung,  for  new  equip- 
ment. The  total  amount  of  these  appropria- 
tions, including  sums  payable  in  subsequent 
years,  was  387,000.  Since  the  funds  available 
for  this  purpose  are  limited,  eifort  is  made  to 
select  for  aid  progressive  institutions  in  large 
cities  where  the  prospects  for  securing  local  sup- 
port are  best  and  where  the  widest  influence  can 
be  exercised.  Grants  have  thus  far  been  made 
to  only  one  Chinese  hospital,  but  as  time  goes  on 
it  may  be  possible  to  extend  the  service  to  addi- 
tional Chinese  institutions,  the  best  of  which  are 
already  attaining  standards  not  lower  than  those 
of  the  better  mission  hospitals. 

The  appropriations  to  mission  hospitals  for  the 
salaries  of  additional  foreign  doctors  and  nurses 
have  served  to  demonstrate  that  the  foreign 
hospital  in  China,  no  less  than  the  Chinese  insti- 
tutions, must  depend  for  their  future  personnel 
more  and  more  on  the  local  medical  and  nurse 
training  schools.     Grants  made  as  early  as  1915, 


300       THE  ROCKEFELLER  FOUNDATION 

for  additional  foreign  doctors  and  nurses  in  two 
hospitals,  remained  unused  in  1921;  and  under 
many  appropriations  made  one  and  two  years 
later,  payments  had  not  yet  been  called  for,  as  the 
necessary  workers  had  not  been  found.  If  ef- 
fective relief  is  to  be  brought  to  the  small  hospi- 
tal, therefore,  the  medical  schools  must  first  be 
helped  to  produce  more  and  better  qualified 
Chinese  doctors  and  highly  trained  Chinese 
nurses. 

There  is  no  doubt  that  eventually  such  Chinese 
workers  will  prove  far  more  useful  than  the  aver- 
age foreigner,  who  is  always  at  a  disadvantage 
when  working  in  a  country  not  his  own.  The 
gradual  substitution  of  Chinese  personnel,  even 
at  salaries  equal  to  the  very  meagre  salaries  now 
paid  to  foreign  missionaries,  will  bring  great 
economies,  for  it  is  often  forgotten  that  the  total 
cost  of  maintaining  a  missionary  in  China  is 
practically  double  the  amount  of  his  salary,  on 
account  of  the  cost  of  travel  to  and  from  the  mis- 
sion field  and  other  special  expenses  that  would 
not  be  incurred  in  the  case  of  Chinese.  It  seems 
clear  that  it  will  be  necessary  to  pay  Chinese 
doctors  larger  salaries  than  in  the  past,  yet  even 
with  the  more  liberal  compensation  there  need 
be  no  fear  that  men  will  be  induced  to  go  into 
mission  medical  work  from  purely  mercenary 
motives.     Already,  some  well-qualified  Chinese 


CHINA  MEDICAL  BOARD  3OI 

doctors  engaged  in  private  practice  have  in- 
comes much  larger  than  the  salary  of  any  foreign 
medical  missionary. 

B.  Fellowships  and  Scholarships 

During  the  year  1921  the  sum  of  327,422.82 
was  expended  on  fellowships  and  scholarships  for 
use  in  Peking  and  abroad.  Twenty-four  foreign 
doctors  and  five  foreign  nurses  were  designated 
for  such  aid  during  the  year,  and  new  grants  were 
made  to  seven  Chinese  doctors  and  one  Chinese 
dietitian.  One  fellowship  was  granted  to  an 
American  teacher  of  physics  to  prepare  him  to 
aid  in  the  development  of  pre-medical  instruction 
in  the  Peking  district.  Special  consideration  is 
given  to  teachers  in  medical  and  pre-medical 
schools,  and  to  nurses  in  hospitals  where  training 
schools  are  conducted.  In  the  case  of  doctors  in 
other  than  teaching  hospitals  the  aid  given  is 
usually  no  more  than  enough  to  pay  the  ordinary 
tuition  expenses  in  American  schools. 

Through  the  assistance  of  the  Director  of  the 
Division  of  Medical  Education  of  the  Rockefeller 
Foundation,  temporary  teaching  appointments 
at  one  of  the  leading  medical  schools  of  the  United 
States  were  secured  for  two  teachers  in  a  medical 
school  in  China.  These  appointments,  besides 
carrying  a  small  compensation,  afforded  op- 
portunities for  a  considerable  amount  of  private 


302       THE  ROCKEFELLER  FOUNDATION 

Study  and  for  intimate  acquaintance  with  the 
methods  of  organization  and  teaching  that  have 
proved  successful  in  the  United  States.  The 
demand  for  assistants  in  the  science  departments 
of  American  universities  is  so  much  greater  than 
the  supply  that  there  should  be  room  for  the 
extension  of  this  service  for  the  benefit  of  teach- 
ers on  furlough  from  China,  to  whom  practical 
experience  of  this  sort  would  often  prove  even 
more  useful  than  a  year  spent  exclusively  in 
study.  The  beneficial  effects  of  these  various 
aids  to  medical  workers  on  furlough  have  been 
very  marked  in  the  raising  of  standards  of  medi- 
cal schools  and  hospitals  in  China. 

The  results  of  the  fellowships  granted  to  Chi- 
nese doctors,  nurses,  pharmacists,  and  medical 
students  for  study  in  the  United  States  have  been 
particularly  gratifying,  in  view  of  the  general 
feeling  in  China  that  students  sent  abroad  for 
study  have  not  on  their  return  justified  the 
hopes  that  have  been  placed  in  them  and  have 
failed  to  find  satisfactory  employment.  If  the 
criticism  is  just  in  the  case  of  men  in  other 
branches  of  learning — which  is  not  yet  clear — it 
is  certainly  not  so  in  the  case  of  most  of  the  stu- 
dents whom  the  Board  has  aided.  The  following 
table  shows  the  present  status  of  forty-five 
Chinese  who  have  been  aided  by  the  Board 
since  the  beginning  of  its  work; 


CHINA  MEDICAL  BOARD 


303 


OCCUPATION 

DOCTORS 

NURSES 

PHARMA- 

TOTAL 

CISTS 

AT  WORK 

APPTS. 

ACCEPTED 

Institutional  work: 

Peking   Union    Medical 

College 

14 

4 

1 

1 

20 

Hunan-Yale     and     Red 

Cross,  Changsha 

6 

1 

1 

1 

9 

Shantung  Christian  Uni- 

versity   

1 

1 

2 

St.  John's  University .  . . 

1 

.  . 

.  . 

1 

Chinese  Government  Se- 

rum Institute 

2 

2 

Chinese  hospitals 

2 

i 

3 

Mission  hospitals 

2 

2 

In  private  practice 

1 

1 

Present  work  not  known  .  . 

2 

2 

Died 

"i 

1 

Studying  in  U.  S.  without 

definite  appointments  .  . 

1 

1 

6 

3 

2 

Totals 

36 

45 

Some  of  the  students  aided  are  now  among  the 
most  promising  members  of  the  faculties  of 
medical  schools,  and  practically  all  are  usefully 
employed  in  institutions  where  they  will  have  a 
chance  to  develop  further  under  favorable  condi- 
tions. The  Chinese  institutions  in  which  five 
persons  are  reported  are  well  organized  and 
should  provide  opportunities  for  effective  work. 
The  three  nurses  who  completed  their  training 
are  doing  good  work  in  well-equipped  hospitals 
in  China,  and  a  place  is  ready  for  the  fourth, 
who  will  shortly  complete  her  course.  The  two 
nurses  whose  present  occupation  is  unknown  did 
not  receive  any  considerable  aid.  They  were 
unable  to  complete  their  courses  in  the  United 
States,  one  of  them  because  of  ill  health. 


304       THE  ROCKEFELLER  FOUNDATION 

C.  Miscellaneous 

Grants  in  aid  of  the  translation  and  terminol- 
ogy work  of  the  China  Medical  Missionary  As- 
sociation and  the  National  Medical  Association 
were  continued  during  the  year  1921.  The 
preparation  of  a  modern  scientific  terminology  is 
of  fundamental  importance  for  the  development 
of  an  independent  Chinese  medical  profession. 
At  present  Chinese  doctors  educated  under  dif- 
ferent foreign  influences  in  China  and  abroad 
depend,  for  discussion  of  scientific  matters,  either 
on  one  of  at  least  four  foreign  languages,  English, 
French,  German,  or  Japanese,  or  on  different 
systems  of  entirely  inadequate  Chinese  nomen- 
clature. This  has  tended  to  break  up  the  medi- 
cal profession  into  numerous  cliques  which  can- 
not easily  have  professional  intercourse  with  one 
another.  Under  the  auspices  of  the  Ministry  of 
Education  a  terminology  commission  has  now 
been  established,  in  which  the  Ministry  and  most 
of  the  higher  educational  institutions  of  the 
country  are  represented.  This  commission  meets 
annually  to  discuss  the  work  done  by  its  mem- 
bers and  to  make  recommendations  to  the 
government  for  the  formal  sanction  of  the  terms 
agreed  upon.  Considerable  progress  has  already 
been  made  with  the  terms  for  the  fundamental 
sciences. 


CHINA  MEDICAL  BOARD  305 

The  Board  has  endeavored  to  assist  in  various 
ways  the  work  of  the  newly  organized  Council  on 
Hospital  Administration  of  the  China  Medical 
Missionary  Association.  In  1921  the  traveling 
expenses  of  members  of  the  Council,  to  attend  a 
meeting  at  Shanghai,  were  paid,  and  arrange- 
ments were  made  for  experts  in  the  employ  of  the 
Board  or  the  Peking  Union  Medical  College  to 
attend  the  meeting  and  advise  on  architectural 
problems,  purchasing,  and  X-ray  installation. 
Dr.  Houghton,  at  the  request  of  the  Association, 
prepared  forms  for  mission  hospital  accounts,  and 
one  edition  of  account  books  printed  according 
to  these  forms  was  published  at  the  expense  of  the 
China  Medical  Board.  These  books  are  now  in 
use  in  several  hospitals  in  China.  The  X-ray 
department  of  the  College  has  given  advice  re- 
garding purchase  of  X-ray  equipment,  and  has 
even  assisted  in  the  actual  installation  and  repair 
of  apparatus  for  mission  and  other  hospitals. 

An  appropriation  of  35,000  Mex.  was  made  to 
the  North  China  Union  Language  School,  for 
repairs  and  equipment.  The  Peking  Union 
Medical  College  depends  on  this  school  for  the 
instruction  in  Chinese  of  those  members  of  its 
foreign  staff  who  need  for  their  work  at  least 
some  knowledge  of  the  language  of  the  people. 
The  school  has  also  been  attended  by  some  of  the 
Chinese  staff  from  the  southern  provinces,  who 

19 


306      THE  ROCKEFELLER  FOUNDATION 

were  not  familiar  with  the  language  as  spoken  in 
North  China. 

An  appropriation  for  emergency  sanitary  work 
was  made  during  the  famine  of  1921,  but,  the 
relief  organization  being  able  eventually  to  care 
for  this  work  themselves,  the  fund  was  not  used. 

While,  under  normal  conditions,  the  China 
Medical  Board  does  not  itself  undertake  any 
public  health  activities,  mention  should  be  made 
of  the  very  successful  work  of  the  Joint  Council 
on  PubHc  Health  Education  maintained  by  the 
National  Medical  Association  of  China,  the  China 
Medical  Missionary  Association,  the  Young 
Men's  and  Young  Women's  Christian  Associa- 
tions and  the  China  Christian  Educational  Asso- 
ciation. The  Council  prepares  literature  on  public 
and  private  hygiene  and  conducts  public  health 
campaigns  in  the  leading  cities.  A  laboratory  is 
maintained  at  Shanghai,  where  charts  and  a 
number  of  ingenious  devices  have  been  prepared 
to  illustrate  important  points  in  the  lectures.  A 
large  collection  of  slides,  and  some  moving  pic- 
ture films,  are  kept  on  hand  for  use  by  the  stail 
or  to  be  lent  to  persons  all  over  the  country  for 
lecturing  on  public  health.  The  extension  de- 
partment of  the  Shantung  Christian  University 
has  also  been  participating  actively  in  this  work 
through  a  special  public  health  exhibit  in  its 
museum  and  through  largely  attended  popular 


CHINA  MEDICAL  BOARD  307 

lectures.  Such  popular  health  education  has  a 
distinct  bearing  on  the  progress  of  medical  educa- 
tion, since  it  serves  to  stimulate  interest  in  study 
for  the  medical  profession  and  incidentally  gives 
the  people  an  idea  of  the  aims  of  the  medical 
schools. 

Two  years  ago  the  Council  on  Public  Health 
Education  conducted  in  the  city  of  Foochow  a 
very  effective  campaign  of  education  against 
cholera,  as  a  result  of  which  the  deaths  from  the 
disease  were  reduced  to  an  insignificant  number 
in  that  city  while  other  cities  in  the  province 
continued  to  suffer  severely.  This  successful  ef- 
fort interested  Chinese  insurance  men  in  the 
possibilities  of  pubHc  health  work  as  a  business 
proposition. 

In  other  places  outbreaks  of  plague,  cholera, 
typhus,  and  other  epidemics,  in  which  Chinese 
and  foreign  physicians  successfully  co-operated 
to  protect  the  communities  in  which  they  were 
working,  not  only  served  to  draw  the  attention  of 
the  authorities  and  the  people  to  the  necessity  for 
public  health  organization,  but  resulted  also  in 
increased  support  for  local  hospitals.  In  many 
cities  physicians  are  being  appealed  to  for  aid  in 
the  medical  inspection  of  school  children  and  in- 
mates of  government  institutions.  Only  the  lack 
of  adequately  trained  personnel  appears  to  pre- 
vent the  rapid  development  of  such  activities. 


308      THE  ROCKEFELLER  FOUNDATION 

Toward  the  end  of  the  year  1921  the  first  steps 
were  taken  for  the  organization  of  a  purely 
Chinese  national  health  association  under  the 
leadership  of  Dr.  S.  M.  Woo,  a  graduate  of  the 
Johns  Hopkins  University  Medical  School,  who 
took  his  public  health  course  at  Harvard  and 
later  served  as  health  officer  at  Canton.  This 
association  has  the  support  not  only  of  the 
Chinese  medical  profession  but  of  leading  states- 
men In  all  parts  of  the  country,  not  even  except- 
ing the  ofiicials  of  the  southern  government  at 
Canton.  Among  its  purposes  are  the  promotion 
of  public  health  education  In  schools  and  colleges, 
the  preparation  of  mobile  units  to  fight  epidemics, 
the  demonstration  of  a  modern  health  organiza- 
tion in  a  selected  locality,  the  maintenance  of  a 
health  museum,  and  research. 

The  International  Health  Board  of  the  Rocke- 
feller Foundation  has  contributed  to  the  public 
health  movement  in  China  by  assigning  to  the 
Peking  Union  Medical  College  a  member  of  its 
staff,  Dr.  John  B.  Grant,  as  associate  professor  of 
hygiene  and  public  health. 

Publications  of  Staff  Members,  Peking  Union 
Medical  College,  1921 

1.  Preliminary  survey  of  the  parasites  of  vertebrates  of  North  China. 

E.  C.  Faust,  China  Medical  Journal,  v.  35,  p.  196-210,  3  tab.,  3 
charts. 

2.  Analyses  of  some  Chinese  foods.     H.  C.  Embrey,  China  Medical 

Journal,  v.  35,  p.  247-257,  5  pis.,  1  tab. 


CHINA  MEDICAL  BOARD  309 

3.  Bacteriological  examination  of  smears  from  1004  consecutive  eye 

cases.  T.  C.  Pa,  National  Medical  Journal  of  China,  v.  7,  p.  52-53, 
1  tab. 

4.  The  office  of  Imperial  physicians,  Peking.     E.  V.  Cowdry,  Journal  of 

the  American  Medical  Association,  v.  77,  p.  307-316,  5  figs. 

5.  Intestinal    parasitism   in    South    Fukien.     J.   P.   Maxwell,    China 

Medical  Journal,  v.  35,  p.  377-382. 

6.  Further  statistics  on  communicable  diseases  among  domestic  servants. 

J.  H.  Korns,  China  Medical  Journal,  v.  35,  p.  382-384,  3  tab. 

7.  The  human  trichomonas  in  North  China.     E.  C.  Faust,  American 

Journal  of  Hygiene,  v.  1,  p.  410-418,  1  pi. 

8.  A  comparison  of  ancient  Chinese  anatomical  charts  with  the  Fiinf- 

bilderserie  of  SudhofF.  E.  V.  Cowdry,  Anatomical  Record,  v.  22, 
p.  1-13,  6  pis.,  24  figs. 

9.  On  an  unusual  anomaly  of  the  Peroneus  tertius  in  a  Chinese.     P.  H. 

Stevenson,  Anatomical  Record,  v.  22,  p.  81-83,  1  fig. 

10.  The  extrahepatic  biliary  tract  of   the    camel.     P.  H.    Stevenson, 

Anatomical  Record,  v.  22,  p.  85-93,  2  figs.,  1  tab.,  1  pi.,  4  figs. 

11.  The  excretory  system  in  digenea  (trematoda):  IV.  A  study  of  the 

structure  and  development  of  the  excretory  system  in  a  cystocer- 
cous  larva,  Cercaria  pekinensis  nov.  spec.  E.  C.  Faust,  Parasi- 
tology, v.  13,  p.  205-212,  6  figs. 

12.  Ray's  "hemolytic"  test  in  kala-azar.     R.  H.  P.  Sia,  China  Medical 

Journal,  v.  35,  p.  397-399,  1  tab. 

13.  Agglutination  titer    following    repeated  intravenous    injections    of 

TAB  vaccine.  C.  H.  Han  and  C.  W.  Young,  China  Medical 
Journal,  v.  35,  p.  400-404,  2  figs. 

14.  The  present  state  of  the  schistosome  problem.     E.  C.  Faust,  China 

Medical  Journal,  v.  35,  p.  405-410. 

15.  The  investigation  of  some  Chinese  foods.     H.  C.  Embrey,  China 

Medical  Journal,  v.  35,  p.  420-447,  36  charts. 

16.  The  use  of  fine  silk  in  surgery.     A.  S.  Taylor,  China  Medical  Journal^ 

V.  35,  p.  467-472,  1  chart. 

17.  Notes  on  South  African  larval  trematodes.     E.  C.  Faust,  Journal  of 

Parasitology,  v.  8,  p.  11-21,  2  figs.,  1  pi.,  13  figs. 

18.  A  case  of  Glioma  retinae.     H.  T.  Pi,  China  Medical  Journal,  v.  35, 

p.  499-503,  3  pis. 

19.  A  collection  of  Chinese  embryos.     P.  H.  Stevenson,  China  Medical 

Journal,  v.  35,  p.  503-520,  3  figs.,  5  tab. 

20.  Mastoiditis  in  Peking.     A.  M.  Dunlap,  China  Medical  Journal,  v.  35, 

p.  521-527. 

21.  Serum   globulin   in   kala-azar.     R.  H.  P.  Sia  and  H.  Wu,  China 

Medical  Journal,  v.  35,  p.  527-532,  6  tab. 

22.  Preliminary  survey  of  the  intestinal  parasites  of  man  in  the  Central 

Yangtze  valley.  E.  C.  Faust  and  C.  M.  Wassell,  China  Medical 
Journal,  v.  35,  p.  532-561,  1  chart,  5  tab. 

23.  Toxicity  of  antimony   in   rabbits.     J.   H.   Korns.    China   Medical 

Journal,  v.  35,  p.  564-566,  1  tab. 


3IO      THE  ROCKEFELLER  FOUNDATION 

24.  Filarlasis  In  China.    J.  P.  Maxwell,  Philippine  Journal  of  Science^ 

V.  19,  p.  257-327,  7  tab.,  4  figs.,  25  pis. 

25.  The  menace  of  insanity  to  popular  government.      A.  H.  Woods, 

National  Medical  Journal  of  China,  v.  7,  p.  201-204. 

26.  Result  of  refraction  In  the  Peking  Union  Medical  College.     T.  T. 

Dzen,  National  Medical  Journal  of  China,  v.  7,  p.  206-308,  4  tab. 

27.  A  study  of  trichomonas  of  the  guinea-pig  from  Peking.     E.  C.  Faust, 

Archiv  fur  Protistenkunde,  v.  44,  p.  115-118,  1  fig.,  1  tab.,  1  pi. 

28.  Incidence   of  vaccination  and  smallpox   in   North  China.     J.  H. 

Korns,  China  Medical  Journal,  v.  35,  p.  561-563. 

29.  Studies  on  the  retina:  Histogenesis  of  the  visual  cells  in  amblystoma. 

S.  R.  Detwiler  and  H.  Laurens,  Journal  of  Comparative  Neurology, 
V.  33,  p.  493-508,  13  figs. 


DIVISION  OF  MEDICAL  EDUCATION 
Report  of  the  General  Director 


To  the  President  of  the  Rockefeller  Foundation : 
Sir: 

I   have  the   honor   to    submit    herewith    my 
report  as  General  Director  of  the  Division  of 
Medical  Education   for   the  period  January  1, 
1921,  to  December  31,  1921. 
Respectfully  yours, 

RICHARD  M.  PEARCE, 

General  Director. 


313 


DIVISION    OF   MEDICAL 
EDUCATION 

During  1921  the  Division  of  Medical  Educa- 
tion, in  pursuance  of  the  objects  for  which  it  was 
estabHshed  in  December,  1919,  included  in  its 
program  the  following  main  activities:  (1)  sur- 
veys of  medical  education  in  the  Far  East;  (2) 
resident  counsel  in  the  development  of  the  Pe- 
king Union  Medical  College  at  Peking,  China,  and 
studies  of  conditions  in  medicine  and  pre-medi- 
cal  science  throughout  China;  (3)  co-operation 
in  programs  of  medical  education  in  the  Americas 
and  Europe;  and  (4)  arrangements  for  observa- 
tion and  study  by  commissions  and  fellows. 

I.     Surveys  in  the  Far  East 

The  Director  of  the  Division  spent  the  year 
1921  in  the  Far  East.  Here  he  made  surveys 
of  the  conditions  and  requirements  of  medical 
education  in  various  localities,  including  Japan, 
Hong  Kong,  Siam,  the  Philippines,  the  Straits 
Settlements,  and  Indo-China,  as  well  as  in  China 
proper.  Following  is  a  brief  summary  of  condi- 
tions as  observed  in  these  countries  and  districts. 

Japan 

In  Japan  and  regions  under  Japanese  influence 
medical   education    is    making    rapid    progress. 

315 


316 


THE  ROCKEFELLER  FOUNDATION 


Fig.  87. — Important  schools  of  medicine  in  the  Far  East 

The  organization  of  the  medical  schools  is  sim- 
ilar to  that  of  German  schools.  The  best  of 
these  institutions  are  on  a  level  with  those  of 
other  progressive  countries.  The  Japanese  seem 
abundantly  able  to  carry  out  needed  develop- 
ments  in   the  fields  of  medical  education  and 

research. 

Hong  Kong 

In   countries    surrounding   the   South    China 

Sea  it  is  notable  that  medical  schools  have  been 


DIVISION  OF  MEDICAL  EDUCATION  317 

established  and  maintained  at  chief  points  on 
regular  trade  routes.  Hong  Kong,  Manila,  and 
Singapore  are  such  ports  of  call  for  ocean  traffic 
in  this  region,  maintaining  contact  with  a  wide 
surrounding  territory.  The  University  of  Hong 
Kong,  for  example,  has  in  the  last  seven  years 
enrolled  114  medical  students,  drawn  from  differ- 
ent areas  as  follows:  fifty  from  the  Straits  Settle- 
ments, thirty-seven  from  Hong  Kong  itself,  nine- 
teen from  various  parts  of  China  proper,  two 
each  from  India,  the  Philippines,  and  Siam,  and 
one  each  from  Australia  and  Sumatra.  Hong 
Kong  is  one  of  the  two  commercial  centers  of 
southern  China.  The  nearest  medical  schools  to 
the  south,  are  at  Manila,  Bangkok,  and  Singa- 
pore, and  to  the  north,  at  Shanghai.  Being  a 
British  colony,  it  has  the  advantage  of  offering 
the  Chinese  student  association  with  European 
institutions  and  point  of  view  while  allowing 
him  to  keep  in  touch  with  the  best  of  Chinese 
life  and  traditions.  The  Faculty  and  Senate  of 
the  University  of  Hong  Kong  have  developed 
good  laboratories  and  are  interested  in  medical 
teaching  on  an  academic  basis.  From  lack  of 
funds  they  have  been  unable  to  put  into  effect 
their  complete  plans  for  teaching  organization. 

Siam 

Recently  interest  in  public  health  and  medical 
education  has  developed  in  Siam,  and  an  admir- 


318 


THE  ROCKEFELLER  FOUNDATION 


1.  CHIBA 

Chiba  Special  Medical  School 

2.  FUKUOKA 

Imperial  University  of  Kyushu 

3.  KANAZAWA 

Kanazawa  Special  Medical  School 

4.  KUMAMOTO 

Kumamoto  Medical  School 

5.  KYOTO 

Imoerial  University  of  Kyotd 
Kyoto  Medical  School 

6.  NAGOYA 

Aichi  Medical  School 

7.  NAGASAKI 

Nagasaki  Special  Medical  School 

8.  NIIGATA 

Niigata  Special  Medical  School 

9.  OKAYAMA 

Okayama  Special  Medical  School 

10.  OSAKA 

Osaka  Medical  College 

11.  SAPPORO 

Imperial  University  of  Hokkaido 

12.  SENDAI 

Tohoku  imperial  University 
Special  Medical  Department 

13.  TOKYO 

Charity  Hospital  Medical  School 
Imperial  University  of  Tokyo 
Tokyo  Woman's  Special  Niedical 
School 
Nippon  Special  Medical  School   . 


Jhokkaido 


Ir^ 


^rV^o^   KYUSHU 


^'•°         ^  MEDICAL  SCHOOLS 

0'^         ^  IN 

*^  JAPAN 


1'^ 


Fig.  88. — Medical  schools  in  Japan 


DIVISION  OF  MEDICAL  EDUCATION  3I9 

able  plan  has  been  made  for  public  health 
organization.  The  chief  difficulty  is  lack  of 
personnel  to  administer  the  actual  work.  Siam 
illustrates  the  final  dependence  of  public  health 
programs  on  adequate  medical  education.  It 
is  estimated  that  95  per  cent  of  the  inhabitants 
have  no  other  medical  attention  than  that  of 
the  native-trained  Siamese  or  Chinese  doctors, 
or  that  of  priests,  "spirit  doctors,"  and  so  forth. 
Possibly  not  more  than  1  per  cent,  and  these 
only  in  Bangkok  or  in  mission  centers,  can  have 
the  attention  of  physicians  trained  in  modern 
medicine.  In  this  connection  it  should  be  borne 
in  mind  that  Siam  is  an  agricultural  country, 
with  small,  widely  scattered  communities  and 
only  two  cities  of  more  than  10,000  inhabitants. 
Few  of  these  communities  could  under  any 
circumstances  maintain  a  modern  medical  prac- 
titioner. The  desire  for  modern  medical  treat- 
ment is  still  to  be  inculcated  in  the  mass  of 
the  Siamese  by  the  government  medical  and 
public  health  services.  These  government  serv- 
ices themselves,  however,  to  carry  out  their 
programs  need  both  well-trained,  fully  qualified 
doctors  and  also  men  of  shorter  training  to  serve 
as  sanitary  inspectors,  hospital  assistants,  and 
so  forth.  At  present  not  enough  men  are  being 
trained  to  meet  the  demands  of  government 
services  alone.     This  condition  is  due  to  several 


320      THE  ROCKEFELLER  FOUNDATION 

causes:  the  period  of  training  for  medicine  is 
longer  than  for  any  other  profession  in  Siam, 
while  the  financial  returns  are  not  greater.  In 
fact,  the  income  of  physicians  is  not  so  large  as 
that  of  lawyers,  for  whom  the  course  of  study  is 
three  years  shorter.  The  problem  is  further 
complicated  by  the  small  number  of  graduates 
of  secondary  schools — at  present  forty  to  sev- 
enty men  a  year — from  which  to  recruit  all  the 
professions. 

The  Royal  Medical  College  of  Bangkok  is  a 
department  of  the  Chulalonghorn  University 
and  is  under  direct  control  of  the  Minister  of 
Education,  who  is  responsible  only  to  the  King. 
The  buildings  of  the  medical  school  are  inade- 
quate for  the  purposes  for  which  they  are  now 
used.  It  is  believed,  however,  that  they  repre- 
sent a  nucleus  of  laboratories  and  hospital 
buildings  around  which  a  creditable  medical 
school  could  be  developed. 

Straits  Settlements 

The  King  Edward  VII  Medical  School  at 
Singapore,  although  it  has  received  considerable 
endowment  from  local  merchants,  is  an  integral 
part  of  the  Colonial  Government  and  essentially 
a  sub-department  of  the  Medical  Service  of  the 
Straits  Settlements  and  the  Federated  Malay 
States.    It  was  not  established  primarily  for  the 


Fig.  89. — Building  for  pathology  and  tropical  medicine, 
Faculty  of  Medicine,  Hong  Kong  University 


Fig.  90. — College  of  Medicine  and  Surgery,  University 
of  the  Philippines,  Manila 


Fig.  91. — Wing  of  General  Hospital,  Manila,  Philippine 
Islands 


Fig.  92. — New  medical  building,  University  of  Alberta, 
Edmonton,  Province  of  Alberta,  Canada 


DIVISION  OF  MEDICAL  EDUCATION  323 

training  of  private  practitioners,  but  for  supply- 
ing the  needs  of  the  Medical  Service.  Scholar- 
ships are  provided  for  about  90  per  cent  of  its  stu- 
dents and  preference  is  now  given  to  applicants 
from  local  sources,  although  formerly  about  half 
the  students  came  from  India  and  Ceylon — none 
from  Siam.  It  is  understood  that  the  standard 
of  student  qualifications  has  been  raised  to  that 
of  an  English  university  medical  school.  As  the 
school  is  not  a  department  of  a  university,  how- 
ever, it  cannot  grant  degrees,  although  it  gives 
the  diploma  of  Licentiate  in  Medicine  and 
Surgery.  Plans  have  been  approved  for  medical 
teaching  on  a  university  basis,  but  recent  finan- 
cial depression  has  made  it  necessary  to  postpone 
putting  these  into  eflPect.  The  school  is  of  the 
greatest  importance  in  the  field  for  which  it  was 
established — that  of  satisfying  the  Govern- 
ment's needs  in  medical  and  public  health 
personnel. 

Indo-China 

In  Indo-China  the  Government  maintains  a 
medical  school  at  Hanoi.  This  school  in  the 
past  has  been  concerned  chiefly  with  the  training 
of  men  for  the  Colonial  Government  services^ 
such  men  entering  the  medical  school  without 
extensive  preliminary  training.  During  the  past 
year,  in  view  of  the  development  of  the  Univer- 
sity at  Hanoi,  a  more  thorough  system  of  teach.- 

20 


324       THE  ROCKEFELLER  FOUNDATION 

ing  has  been  developed,  and  at  the  end  of  four 
years  in  Hanoi  students  will  be  sent  to  France 
for  a  year  of  postgraduate  instruction.  Thus 
far,  only  a  small  number  of  students  have  entered 
the  higher  course,  and  the  older  school  with 
lower  standards  continues. 

Philippine  Islands 

In  the  Philippines,  Governor  General  Leonard 
Wood,  himself  a  physician,  is  eager  to  develop 
in  every  way  the  medical  and  public  health  re- 
sources of  the  Islands.  He  has  invited  the 
co-operation  of  the  Rockefeller  Foundation 
and  of  its  International  Health  Board.  The 
invitation  has  been  accepted  on  the  part  of 
the  International  Health  Board,  and  the  Di- 
vision of  Medical  Education  hopes  to  be  able 
to  participate  by  lending  temporarily  the  serv- 
ices of  an  associate  dean  for  the  College  of 
Medicine  and  Surgery  of  the  University  of  the 
Philippines. 1  The  pre-medical  departments  of 
the  University — physics,  chemistry,  and  biology 
— are  spaciously  housed,  well-equipped,  well- 
manned,  and  doing  good  work.  The  Medical 
School  itself  has  excellent  laboratories,  it  is  in 
close  affiliation  with  the  Manila  General  Hospital, 

^In  March,  1922,  Dr.  William  S.  Carter,  Dean  of  the  University  of 
Texas  Medical  School,  on  leave  of  absence,  sailed  for  Manila  to  accept 
this  post. 


DIVISION  OF  MEDICAL  EDUCATION  325 

and  the  prospects  for  development  under  Fili- 
pino management  are  good.  It  is  thought, 
however,  that  this  development  can  be  hastened 
by  continued  co-operation  for  the  present  on  the 
part  of  those  interested  in  Western  medicine. 

II.     Peking  Union  Medical  College  and  Studies 
in  China 

For  the  greater  part  of  the  year,  the  Director 
of  the  Division  of  Medical  Education  served  in 
China,  making  for  the  China  Medical  Board  of 
the  Rockefeller  Foundation  a  general  survey  of 
medical  and  pre-medical  education  in  China, 
and  acting  in  an  advisory  capacity  to  the  Peking 
Union  Medical  College.  The  College  which  has 
been  erected  and  is  being  maintained  by  funds 
from  the  Rockefeller  Foundation,  was  going 
through  a  formative  period  with  the  completion 
of  its  new  buildings  and  the  installation  of  its 
various  departments  in  their  permanent  quarters. 
Problems  of  organization  had  consequently  to  be 
solved.  The  Director  of  the  Division  served  also 
as  Acting  Director  of  the  College  for  several 
months  during  the  absence  of  Director  Henry 
S.  Houghton.  A  further  account  of  the  work  in 
China  during  1921  will  be  found  in  the  annual 
report  of  the  China  Medical  Board. 


326       THE  ROCKEFELLER  FOUNDATION 

III.     The  Americas  and  Europe 
The  United  States 

In  the  United  States  the  Foundation  co- 
operated with  the  General  Education  Board  in 
support  of  plans  for  reorganizing  and  rebuilding 
the  medical  schools  of  Columbia  University  and 
the  University  of  Chicago. 

Canada 

In  the  various  Canadian  medical  schools  to 
which  the  Foundation  in  1920  pledged  assist- 
ance progress  was  made  during  1921. 

At  Dalhousie  University,  Halifax,  the  facilities 
of  the  compactly  arranged  group  of  buildings 
representing  the  medical  school  and  hospital 
have  recently  been  enlarged  by  the  erection, 
under  the  Salvation  Army,  of  a  maternity  hos- 
pital, soon  to  be  opened.  Toward  the  cost  of 
this  hospital  an  additional  appropriation  of 
350,000  was  made  by  the  Foundation  to  the 
University. 

The  36,000,000  endowment  fund  for  which 
McGill  University,  Montreal,  conducted  a  cam- 
paign, was  oversubscribed.  The  Foundation's 
1920  pledge  of  31,000,000  to  this  fund  was 
paid  in  full  during  1921.  The  University  has 
practically  completed  its  new  biological  building 
and  has  made  arrangements  preparatory  to  the 
building  of  a  new  institute  of  pathology. 


DIVISION  OF  MEDICAL  EDUCATION  327 

The  University  of  Toronto,  with  aid  from 
the  Provincial  Government,  has  proceeded  with 
its  building  of  an  institute  of  anatomy,  which 
by  the  end  of  the  year  was  well  under  way. 
Plans  for  the  erection  of  a  psychiatric  hospital 
by  the  city  of  Toronto  on  a  site  granted  by  the 
University  are  in  course  of  preparation. 

The  University  of  Manitoba,  at  Winnipeg,  re- 
ceived from  the  Manitoba  Legislature  during  192 1 
appropriations  sufficient  to  meet  the  conditions 
of  the  Foundation's  pledge  of  1920.  Payments 
on  this  pledge  were  accordingly  begun.  One  of 
the  new  Medical  College  buildings  was  put  into 
use  in  the  course  of  the  year;  and  at  the  end  of  the 
year  the  second  building  was  about  to  be  opened. 

Appropriation  of  225,000  was  continued  for 
a  second  year  to  the  University  of  Alberta, 
at  Edmonton.  An  appropriation  of  a  similar 
sum  was  also  made  for  a  second  year  to  the 
University  of  Montreal,  teaching  in  French, 
which  has  through  this  appropriation  made 
progress  in  developing  the  sciences  preliminary 
to  medicine — developments  which  it  is  hoped 
will  have  a  far-reaching  influence  in  the  training 
of  the  French  medical  profession  of  Canada. 

Brazil 

Following  various  surveys  of  medical  and 
public  health  conditions  in  Brazil,  and  co-opera- 


328       THE  ROCKEFELLER  FOUNDATION 

tion  by  the  Foundation's  International  Health 
Board  in  estabUshing  a  department  of  hygiene 
in  the  Faculdade  de  Medicina  e  Cirurgia  at  Sao 
Paulo,  the  Foundation  was  requested  by  the 
Faculdade  to  select  an  American  professor  to 
build  up  a  modern  department  of  pathology  in 
this  school.  During  1921  Dr.  Oskar  Klotz,  then 
professor  of  pathology  and  bacteriology  in  the 
University  of  Pittsburgh,  was  chosen  for  this 
post  for  a  period  of  two  years,  and  entered  upon 
his  duties.  Provision  has  been  made  by  the 
Foundation  for  supplying  Dr.  Klotz  with  nec- 
essary assistants  and  scientific  equipment  for 
this  work. 

France 
The  attention  of  the  Rockefeller  Foundation 
was  called  to  the  fact  that  the  Pasteur  Institute 
in  Paris,  which  maintains  several  branches,  in- 
cluding those  in  Lille,  Algiers,  West  Africa,  and 
Indo-China,  was  suffering  materially  in  the 
post-war  period,  not  only  from  the  high  cost  of 
necessary  supplies,  but  also  from  the  high  cost 
of  living  which  forced  several  of  its  scientists  to 
seek  positions  elsewhere  in  order  to  maintain  them- 
selves. To  meet  this  temporary  situation  the 
Foundation  gave  to  the  Institute  330,000  for  its 
work  in  1921,  and  pledged  325,000  and  320,000 
respectively  for  1922  and  1923,  with  no  further 
commitment  for  the  future.     It  is  expected  that 


^  '            ''         '   '  '                                                                      ■ .-! 

Fig.  93. — ^The  new  medical  center  In  Brussels.  The 
group  of  buildings  shown  in  the  architect's  sketch,  com- 
bining a  medical  school  and  laboratories,  a  hospital,  and  a 
nurses'  home  and  training  school,  are  being  constructed 
by  the  University  of  Brussels  and  the  Hospital  Board  of 
the  municipality  with  the  aid  of  the  Rockefeller  Foundation 


Fig.  94. — Institute  of  Anatomy,  University  College, 
University  of  London.  Architect's  drawing  of  one  of  the 
new  Institutes  being  erected  with  Foundation  aid 


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DIVISION  OF  MEDICAL  EDUCATION  33 1 

these  funds  will  be  used  largely  for  the  training  of 
new  personnel,  through  the  granting  of  fellow- 
ships and  the  supplying  of  equipment  requisite 
for  such  training. 

Belgium 

Progress  was  made  toward  rebuilding  and 
reorganizing  the  medical  school  of  the  Free 
University  of  Brussels,  to  concentrate  its  fa- 
cilities and  co-ordinate  the  efforts  of  many 
agencies.  Conferences  were  held  in  Brussels 
by  the  President  of  the  Foundation  and  a 
representative  of  the  General  Education  Board; 
a  pledge  of  ?2S0,000 — in  addition  to  the  earlier 
pledge  of  40,000,000  francs  to  this  medical 
school — was  made  by  the  Foundation  for  en- 
dowment of  the  teaching  hospital  of  the  school; 
additional  land  was  ceded  to  the  medical  school 
by  the  city  of  Brussels;  and  the  architect  has 
studied  hospital  and  laboratory  construction  in 
England,  Canada,  and  the  United  States,  as  the 
guest  of  the  Foundation  and  has  almost  com- 
pleted the  first  draft  of  plans  for  the  new 
buildings. 

England 

With  University  College  and  University  Col- 
lege Hospital  in  London  the  final  contracts  in  re- 
gard to  their  medical  school,  by  which  the  Rocke- 
feller Foundation  agreed  to  give  1,205,000  pounds 
for  buildings,  equipment,  and  endowment  were 


332       THE  ROCKEFELLER  FOUNDATION 

executed.  The  new  Anatomy  Building  made 
rapid  progress,  and  desired  property  has  been 
secured  for  the  hospital  building.  Decline  in 
building  costs  has  worked  to  the  advantage  of 
the  medical  school.  A  large  number  of  entering 
students  has  been  reported.  Development  of 
the  full-time,  or  unit,  system  of  teaching  here  is 
being  watched  with  interest  throughout  Great 
Britain. 

Central  Europe 

To  enable  the  universities  of  Continental 
Europe  to  keep  in  touch  with  the  developments 
of  medical  science  in  England  and  America, 
temporary  aid  in  the  supplying  of  important  Eng- 
Hsh-language  medical  journals  was  continued  in 
1921  for  a  second  year  to  the  medical  schools  of 
countries  suffering  from  adverse  exchange.  The 
journals  were  paid  for  by  the  recipients  at  pre- 
war rates  of  exchange.  By  this  means  schools 
were  enabled  to  maintain  their  files  of  important 
journals  at  a  time  when  financial  conditions 
would  otherwise  have  made  it  impossible  for 
them  to  continue  their  subscriptions.  A  few  of 
the  more  important  medical  centers  were  helped 
also  to  obtain  necessary  scientific  equipment 
which  had  been  depleted  during  the  war. 

Medical  journals  were  supplied  during  1921 
to  medical  school  libraries  in  the  following  cit- 
ies: Gratz,  Innsbruck,  and  Vienna,  in  Austria  j 


DIVISION  OF  MEDICAL  EDUCATION  33;^ 

Brussels  and  Ghent,  in  Belgium;  Bratislava, 
Brno,  and  Prague,  in  Czechoslovakia;  Lyons 
and  Paris,  in  France;  Berlin,  Breslau,  Frankfort, 
Freiburg,  Gottingen,  Greifswald,  Hamburg,  Han- 
over, Heidelberg,  Jena,  Kiel,  Cologne,  Leipsig, 
Marburg,  Munich,  Rostock,  Tubingen,  Wies- 
baden, and  Wiirzburg,  in  Germany;  Budapest 
in  Hungary;  Bologna,  Genoa,  Naples,  Rome, 
and  Turin,  in  Italy;  Belgrade  and  Zagreb  in 
Jugoslavia;  and  Cracow,  Lwow,  and  Warsaw, 
in  Poland;  and  also  to  Russian  scientists,  to  whom 
they  were  distributed  through  an  agency  in 
London. 

IV.     Commissions  and  Fellowships 
Commissions 

To  promote  international  exchange  of  medical 
experience  and  thus  to  increase  the  common  fund 
of  knowledge  to  which  all  nations  contribute 
and  upon  which  each  may  freely  draw,  the 
Foundation  has  sought  to  encourage  visits  and 
conferences  between  medical  educators  of  differ- 
ent countries  and  the  postgraduate  study  of 
medicine  by  visiting  fellows  who  will  return  to 
definite  posts  in  their  own  countries.  In  follow- 
ing out  the  first  part  of  this  program,  the  Presi- 
dent of  the  Foundation  during  the  year  visited 
the  medical  centers  in  London  and  Brussels,  first 
with  a  representative  of  the  General  Education 


334       THE  ROCKEFELLER  FOUNDATION 

Board,  and  again  with  the  General  Director  of 
the  Foundation's  International  Health  Board. 

From  several  countries  commissions  made  up 
of  individuals  concerned  in  one  way  or  another 
with  problems  of  medical  education  paid  visits, 
as  guests  of  the  Foundation  or  its  departmental 
boards,  to  medical  centers  of  England,  Canada, 
and  the  United  States. 

A  commission  of  two — Mr.  Armand  Goossens- 
Bara  and  Mr.  J.  B.  Dewin — came  from  Belgium 
to  the  United  States  in  July  and  later  went  to 
England  to  study  the  construction  and  adminis- 
tration of  hospitals  and  medical  schools,  in  the 
interest  of  the  new  medical  center  being  built  in 
Brussels  by  the  aid  of  the  Foundation.  Mr. 
Goossens-Bara  is  president  of  the  Conseil  des 
Hospices,  the  board  which  administers  the  pub- 
lic hospitals  of  the  city  of  Brussels,  including  the 
teaching  hospital  of  the  medical  school  of  the 
Free  University  of  Brussels.  Mr.  J.  B.  Dewin 
is  the  architect  appointed  by  the  University  to 
plan  the  buildings  of  the  new  medical  center. 
Certain  problems  in  the  teaching  of  medicine 
were  studied  in  London  by  three  members  of  the 
faculty  of  the  University  of  Brussels — Dr.  A. 
Brachet,  professor  of  anatomy,  Dr.  Paul  Vander- 
velde,  professor  of  pathological  anatomy,  and 
Dr.  Rene  Verhoogen,  professor  of  pathology. 

During  the   months   of   May   and   June,  Sir 


DIVISION  OF  MEDICAL  EDUCATION  335 

Wilmot  Herringham,  chairman  of  the  Committee 
on  Medical  Education  of  the  University  Grants 
Committee  and  Sir  Walter  Fletcher,  secretary 
of  the  Medical  Research  Council  (English  Privy- 
Council)  visited  representative  institutions  of 
medical  education  and  research  in  Canada  and 
the  United  States.  Also,  in  connection  with  the 
plans  of  the  University  College  Hospital  Medical 
School,  Dr.  A.  E.  Boycott,  professor  of  pathol- 
ogy, and  Dr.  C.  C.  Choyce,  professor  of  surgery, 
paid  a  visit  to  the  United  States  and  Canada  to 
study  methods  of  medical  education  and  research. 

In  September  three  Serbian  physicians  ar- 
rived in  New  York  to  study  medical  education, 
hospital  organization,  and  public  health  admin- 
istration in  representative  institutions  of  the 
United  States  and  Canada.  On  this  commission 
were  Dr.  Georges  J,  Nikolitch,  under-secretary 
and  first  medical  officer  of  the  Ministry  of 
Health  of  the  kingdom  of  the  Serbs,  Croats, 
and  Slovenes,  Dr.  Georges  Joannovitch,  pro- 
fessor of  pathological  anatomy,  and  Dr.  Radenko 
Stankovic,  professor  of  internal  medicine,  in  the 
University  of  Belgrade.  On  leaving  the  United 
States  they  proceeded  to  England  on  the  same 
mission. 

Dr.  Carlos  Chagas,  director  of  the  Oswaldo 
Cruz  Institute  at  Rio  de  Janeiro,  and  Director 
General  of  the  National  Department  of  Health 


336       THE  ROCKEFELLER  FOUNDATION 

of  Brazil,  spent  the  months  of  May  and  June 
in  the  United  States  visiting  medical  and  public 
health  institutions. 

Fellowships 

One  of  the  Foundation's  most  profitable  fields 
of  work  has  been  the  training,  under  fellowships, 
of  men  from  other  countries  who  intend  to  re- 
turn home  to  occupy  positions  of  responsibil- 
ity as  teachers,  investigators,  or  public  health 
officials.  In  addition  to  promoting  international 
co-operation,  continued  experience  has  shown 
that  the  training  of  scientists  and  educators  for 
work  in  their  own  countries  is  the  best  way  in 
the  long  run  to  build  a  firm  foundation  for  medi- 
cal teaching  and  research.  From  small  begin- 
nings, the  selection  and  assistance  of  fellows  has 
developed  into  an  appreciable  part  of  the  work 
of  the  Foundation — so  much  so  that  it  has  been 
found  necessary  to  place  in  charge  of  one  man, 
Dr.  Clifford  W.  Wells,  the  immediate  responsi- 
bility for  the  fellowships  of  the  Foundation  and 
its  boards.  Aside  from  the  fellowships  in  physics 
and  chemistry  supported  by  the  Rockefeller 
Foundation  and  administered  by  the  National 
Research  Council,  a  total  of  123  Foundation 
fellowships  were  in  force  in  the  course  of  the 
year  1921.  Of  these,  fellowships  under  the 
Division   of   Medical   Education  were   held  by 


DIVISION  OF  MEDICAL  EDUCATION  2>2>7 

men  representing  the  following  institutions,  with 
most  of  which  the  Foundation  has  otherwise 
co-operated:  in  Belgium,  the  Free  University 
of  Brussels;  in  Brazil,  the  Faculdade  de  Medicina 
e  Cirurgia  in  Sao  Paulo  and  Oswaldo  Cruz 
Institute  in  Rio  de  Janeiro;  in  Canada,  the 
University  of  Alberta  at  Edmonton,  Dalhousie 
University  at  Halifax,  the  University  of  Mani- 
toba at  Winnipeg,  and  the  University  of  Mon- 
treal; in  England,  University  College,  London; 
and  in  Syria  the  American  University  of  Beirut. 
During  the  past  two  years,  from  different 
sides,  the  attention  of  both  the  Rockefeller 
Foundation  and  the  General  Education  Board 
has  been  called  to  the  shortage  of  medical  teachers 
in  the  United  States.  The  problem  was  dis- 
cussed by  officers  and  members  of  the  General 
Education  Board,  and  by  them  submitted  to  a 
larger  group  interested  in  medical  education, 
including  officers  of  both  organizations.  A  re- 
port of  the  conclusions  of  this  group  resulted  in 
the  passage  by  the  Foundation  and  the  General 
Education  Board  of  concurrent  resolutions  which 
look  toward  co-operation  between  these  organ- 
izations and  the  National  Research  Council  in 
establishing  a  system  of  fellowships  which  should 
tend  to  satisfy  the  present  needs  of  medical 
schools  for  teachers  who  are  both  competent 
instructors  and  original  investigators, 


THE  ROCKEFELLER  FOUNDATION 
Report  of  the  Treasurer 


New  York,  February  9,  1922 

To  the  President  of  the  Rockefeller  Foundation : 

Sir: 

I  have  the  honor  to  submit  herewith  my  report 
of  the  financial  operations  of  the  Rockefeller 
Foundation  and  its  subsidiary  organizations  for 
the  period  January  1,   1921,  to  December  31, 

1921. 

Respectfully  yours, 

L.  G.   MYERS, 

Treasurer. 


21  341 


TREASURER'S  REPORT 

During  the  year  1921  Income  from  general  principal 
fund  and  from  income  temporarily  invested  amounted  to 
38,702,689.70.  Undisbursed  income  carried  over  from  1920, 
after  adding  sundry  refunds,  amounted  to  36,286,669.69. 
A  total  of  314,989,359.39  was  therefore  available  for 
disbursement.  Disbursements  during  the  year  amounted 
to  37,630,358.49,  leaving  a  balance  of  37,359,000.90. 

On  December  31,  1921,  the  total  of  all  unpaid  appro- 
priations and  pledges  amounted  to  323,219,394.11,  as 
follows : 

Balance  due  on  appropriations  pay- 
able in  1921  and  prior  years $4,032,997.71 

Appropriations  and  pledges  which 
become  effective  in  1922  and  fol- 
lowing years: 

1922 $6,280,746.40 

1923 4,619,892.00 

1924 3,460,067.00 

1925 2,596,191.00 

1926 2,229,500.00 

19,186,396.40 

$23,219,394.11 

The  undisbursed  balance  of  income  amounting  to 
37,359,000.90,  reported  above,  is  thus  exceeded  by  the 
total  of  all  unpaid  appropriations  and  pledges  to  the 
extent  of  315,860,393.21.  This  undisbursed  balance  does, 
however,  exceed  unpaid  appropriations  due  in  1921  and 
prior  years  (34,032,997.71)  by  the  sum  of  33,326,003.19. 
Appropriations  and  pledges  effective  in  1922,  amounting  to 
36,280,746.40,  will  be  more  than  covered  by  1922  income 
estimated  at  38,000,000.00;  while  appropriations  and 
pledges  effective  in  1923  and  subsequent  years  will  be  met 
with  income  to  be  received  in  those  years, 

343 


344      THE  ROCKEFELLER  FOUNDATION 

General  principal  funds,  Including  the  reserve  fund, 
increased  during  the  year  from  ?174,3 15,913.06  to 
3174,395,157.50,  a  diiference  of  ?79,244.44.  This  is 
accounted  for  by  gains  on  sales  of  securities  amounting  to 
363,169.24,  and  by  gains  on  sales  of  land  in  China,  amount- 
ing to  316,075.20. 

Income  expended  for  land,  buildings,  and  equipment, 
almost  wholly  in  China,  amounted  to  51,156,227.71, 
which,  added  to  the  balance  carried  over  from  1920,  made 
a  gross  total  of  38,709,063.12.  Depreciation  of  equip- 
ment, sales  of  land  and  material,  and  a  small  gift  of  books, 
amounting  in  all  to  342,250.25,  reduced  this  sum  to  a  net 
total  of  38,666,812.87. 

Since  the  close  of  the  year  the  accounts  of  the  Comp- 
troller, the  accounts  of  the  Treasurer,  and  the  securities 
owned  by  the  Corporation  have  been  examined  by  Messrs. 
Lybrand,  Ross  Bros.  &  Montgomery,  Accountants  and 
Auditors.  A  report  of  their  work  rendered  to  the  Chair- 
man of  the  Board  of  Trustees  will  be  found  on  page  408. 


The  financial  condition  and  operations  are  set  forth  in 
the  appended  exhibits  listed  below: 

Balance  Sheet Exhibit  A 

Statements   of  Receipts   and   Disburse- 
ments of  Income Exhibit  B 

Foundation  Appropriations : 

Medical  Education Exhibit  C 

School  of  Hygiene  and  Public  Health .  Exhibit  D 

Research  in  Physics  and  Chemistry. .  .  Exhibit  E 

Mental  Hygiene Exhibit  F 


TREASURER  S   REPORT  345 

Hospital,    Dispensary,    and    Nursing 

Studies  and  Demonstrations Exhibit  G 

War  Work Exhibit  H 

Miscellaneous Exhibit    I 

International  Health  Board  Appropria- 
tions    Exhibit    J 

China  Medical  Board  Appropriations  .  .  .  Exhibit  K 
Summary  of  Appropriations   and   Pay- 
ments    Exhibit  L 

Statement  of  Appropriations  and  Pay- 
ments of  Special  Funds Exhibit  M 

Statements  of  Principal  Funds Exhibit  N 

Land,  Buildings,  and  Equipment  Funds.  Exhibit  0 
Statement  of  Transactions  Relating  to 

Invested  Funds Exhibit   P 

Schedule  of  Securities  in  General  Funds .  Exhibit  Q 

Schedule  of  Securities  in  Special  Funds  .  Exhibit  R 


346  THE   ROCKEFELLER   FOUNDATION 

EXHIBIT  A 

BALANCE  SHEET,   DECEMBER  31,   1921 

ASSETS 
I.  Investments 
General  Fund 

General  Schedule  (Exhibit  Q) $177,694,831 .  93 

Less  amount  of  income  invested  (see  below)  . .  3,299,674 ,  43 


$174,395,157.50 

Special  Funds  (Exhibit  R) 116,800. 00 

$174,511,957.50 


II.  Land,  Buildings,  and  Equipment 

In  China $8,631,832.92 

In  New  York 34,979.95 


$8,666,812.87 


III.  Income  Accounts 

Special  Funds 
Cash  on  deposit  in  New  York $4,862.20 

General  Fund 

Cash  on  deposit  in  New  York $64,599.82 

CashinLondon:  £24,826-6-6 at  $3.7523 93,156.44 

Cash    in    Brussels:    Francs    20,840,577.05    at 

7.3638fi 1,534,685.92 

Moneys  loaned 800,000.00 

Income  invested  temporarily  (Exhibit  Q) 3,299,674 .  43 

Funds  in  hands  of  agents,  to  be 
accounted  for,  and  sundry  ac- 
counts receivable $1,573,108.08 

Less  accounts  payable 6,223 .  79 

~ 1,566,884.29 

Total $7,359,000.90 

Excess  of  appropriations  and  pledges  over  income 

available 15,860,393.21 


23,219,394.11 
$23,224,256.31 
Gi^and  Total.  . , $206,403,026.68 


TREASURER'S   REPORT  347 

EXHIBIT  A 

BALANCE  SHEET,   DECEMBER  31,   1921 

FUNDS  AND  OBLIGATIONS 
I.  Funds 

General  Fund  (Exhibit  N) $171,204,624 .  50 

Reserve  Fund  (Exhibit  N) 3,190,533 .  00 


$174,395,157.50 


Special  Funds 

Gift  of  John  D.  Rockefeller $37,000 .  00 

Gift  of  Laura  S.  Rockefeller 49,300 .  00 

Henry  Sturgis  Grew  Memorial  Fund 25,000 .  00 

Arthur  Theodore  Lyman  Endowment 5,500 .  00 

116,800.00 

$174,511,957.50 

II.  Land,  Buildings,  and  Equipment  Fund 

Appropriations  from  income  (Exhibit  O) $8,666,812 .  87 


III.  Income  Accounts 
Special 

Estate  Laura  S.  Rockefeller  Fund  (Exhibit  B)  . .  $64 .  77 

Henry  Sturgis  Grew  Memorial  Fund  Income 

(Exhibit  B) 4,082.95 

Arthur  Theodore  Lyman  Endowment  Fund  In- 
come (Exhibit  B) 714.48 


$4,862.20 


General  Fund 

Balance  due  on  appropriations  payable  in  1921 

^  and  prior  years  (Exhibit  L) $4,032,997 .  71 

Appropriations  and  pledges  which  become  ef- 
fective in  1922  and  following  years : 

1922 $6,280,746.40 

1923 4,619,892.00 

1924 3,460,067.00 

1925 2,596,191.00 

1926 2,229,500.00 


19,186,396.40 

*23,219,394.11 


$23,224,256.31 


Grand  Total $206,403,026.68 


I 


*The  total  of  all  unpaid  appropriations  and  pledges  is  $15,860,393.21  in  excess  of  the  balance  of  general 
fund  income  amounting  to  $7,359,000 .  90,  as  shown  on  opposite  page,  but.  it  will  be  noted  that  these  obliga- 
tions become  effective  over  a  term  of  years,  thus  permitting  their  satisfaction  gradually  as  the  income  of  the 
respective  years  is  received. 


348 


THE  ROCKEFELLER  FOUNDATION 


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408      THE  ROCKEFELLER  FOUNDATION 

February  18,  1922 
Mr.  John  D.  Rockefeller,  Jr., 
Chairman  of  the  Board  of  Trustees, 
The  Rockefeller  Foundation, 
New  York,  N.  Y. 

Dear  Sir: 

We  have  examined  the  accounts  of 

THE  ROCKEFELLER  FOUNDATION 

for  the  year  ended  December  31,  1921,  and  report  thereon 
as  follows: 

The  assets  recorded  on  the  books  of  account  kept  at  the 
administration  offices  of  the  Foundation,  were  verified  by 
actual  inspection  and  count,  or  by  correspondence  with 
depositories  and  agents  or  by  examination  of  the  latest 
available  financial  reports  or  other  data  pertinent  thereto. 
The  increases  or  decreases  during  the  year  in  the  Founda- 
tion's general  and  special  fund  accounts,  both  principal  and 
income,  and  the  respective  balances  as  of  December  31, 
1921,  were  verified  by  us. 

We  ascertained  that  all  income  receivable  during  the 
year  from  investments,  bank  deposits,  etc.,  had  been 
properly  accounted  for  and  that  all  disbursements  were 
supported  by  vouchers,  properly  approved. 

The  minutes  of  the  respective  Executive  Committees 
and  of  the  Finance  Committee  were  examined  and  we 
noted  that  all  pledges  and  appropriations  had  been  recorded 
on  the  books  of  account  and  that  purchases,  sales  and  con- 
versions of  assets  effected  during  the  year  had  been  duly 
authorized. 

We  hereby  certify  that,  in  our  opinion,  the  accompanying 
balance  sheet,  the  statements  of  income  and  disbursements 
and  of  appropriations  and  disbursements  show  correctly  the 


TREASURER  S   REPORT  409 

financial  position  of  the  Foundation  at  December  31,  1921, 
and  the  result  of  its  financial  activities  for  the  year  ended 
with  that  date. 

Very  truly  yours, 

Lybrand,  Ross  Bros.  &  Montgomery, 

Accountants  and  Auditors. 


INDEX 


INDEX 

PAGE 

AcKERT,  Dr.  J.  E 160, 175 

Agar,  J.  G x,  xi,  79 

Alabama 90, 91,  111,  112, 146, 150, 152, 187, 191,  204,  207,  212,  214 

See  also  Names  of  counties. 

Alagoas  (City)  Brazil 107 

Alagoas  (State)  Brazil 89, 121 

Algiers,  Africa 328 

American  Army  Medical  Commission 53 

American  Board  Hospital,  Fenchow,  Shansi 299 

American  Journal  of  Hygiene 28 

American  Presbyterian  Hospital,  Chefoo,  Shantung 299 

American  Red  Cross 66,  207 

American  University  of  Beirut 337 

Ancylostoma,  see  Hookworms. 
Ancylostomiasis,  see  Hookworm  Disease. 

Andrews,  Chase 80 

Animals: 

Treatment  of  Dogs  with  Carbon  Tetrachloride 142 

Pigs  as  Carriers  of  Hookworm  Disease 176 

Use  in  Mosquito  Control 198 

Anopheles  (Mosquito) 57, 187, 192, 198 

Anti-Hookworm  Campaigns  in  Southern  India,  by  J.  F,  Caius,  K.  S. 

Mhaskar,  and  J.  F.  Kendrick 160 

Anti-Mosquito    Measures,    see    Malaria    Control;    Yellow 

Fever. 
Antitoxin,  see  Toxin-Antitoxin  (for  Diphtheria). 

Argentina 59 

Arkansas 91,  111,  187, 191 

See  also  Names  of  towns. 

ascaridol 141 

Assam,  India 139 

Augusta,  Georgia 200 

Augustine,  D.  L 156, 160, 175 

Australia: 

Progress  of  the  Five-Year  Scheme  under  New  Ministry  of 

Health 136, 139 

413 


PAGE 

Australia — Continued 

Hookworm  Control  Operations 166, 169-170 

Also 62, 89, 92, 93, 95, 142, 377 

See  also  Names  of  towns,  states,  and  territories. 

Australian  Ministry  of  Health 67, 136 

Austria 152,332 

AzEVEDO,  Dr.  Paes  de 89 

Bacon,  Sir  Francis,  quoted 48-49 

Baermann  Apparatus,  see  Hookworms. 

Bahia  (City)  Brazil 107 

Bahia  (State)  Brazil 107 

Bailey,  Dr.  C.  A 90, 92, 204 

Baldwin  County,  Alabama 214 

Baltimore,  Maryland: 

Survey  of  Health  Conditions  Among  Children 29 

Investigation  of  Diphtheria  Situation 29 

Baltimore,  Maryland,  Department  of  Health 27 

Bangkok,  Siam 136,  317,  319 

See  also  Royal  Medical  College  of  Bangkok. 

Barnes,  Dr.  M.  E 90 

Bass,  Dr.  C.  C 91, 115, 156, 160, 193,  note  197 

Bayous,  see  Malaria  Control. 

Beirut,  Syria 68 

See  also  American  University  of  Beirut. 

Belgian  Congo 108 

Belgium 8,  331,  333 

Belgrade,  Jugoslavia 333 

Belize,  British  Honduras 54, 105 

Bell  County,  Kentucky 213 

Bengal,  India 185 

See  also  Darjeeling  (District)  Bengal. 

Benton,  G.  P 280 

Berlin,  Germany 333 

Beta-Naphthol 141 

Biggs,  Dr.  H.  M 80,  88 

Blount  County,  Tennessee 212 

Bolivar  County,  Mississippi 194 

Bologna,  Italy 333 

Bombay 68 

Borneo,  see  British  North  Borneo. 

Botello,  T.  F 92 

Boycott,  Dr.  A.  E 335 

414 


PAGE 

Boyd,  Dr.  M.  F 91,  199 

Bracket,  Dr.  A 334 

Bratislava,  Czechoslovakia 333 

Brazil: 

Center  of  Yellow  Fever  Infection 106-107 

National  Department  of  Health 107, 153-154 

Resurvey  for  Hookworm  Infection 127-129 

Development  of  County  Health  Organization 129-130 

Fellowships 146 

Also 7, 8,  37,  55,  62,  89, 92, 93, 96, 122, 140, 141, 185,  215,  327-328 

See  also  Governor's  Island,  Brazil;  also  Names  of  towns 
and  states. 

Breslau,  Germany 333 

Brisbane,  Queensland 169 

British  East  Indies 292 

British  Guiana 130 

British  Honduras: 

Hookworm  Control 139-140 

Hookworm  Infection  Survey 171-172 

Also 55, 92, 103, 104, 105 . 

British  Ministry  of  Health 35 

British  North  Borneo 62,  89, 135 

British  Solomon  Islands 90, 121, 166, 172 

Brno,  Czechoslovakia 333 

Bruno,  Dr.  Alexander 92 

Brunyate,  Sir  William 280 

Brussels 47,  50,  333,  334 

See  also  Cavell-Depage  Memorial  School  of  Nursing, 
Brussels;  Free  University  of  Brussels. 

Buck,  C.  E 91 

Buckingham  Mills  (Madras) 161, 165-166 

Budapest,  Hungary 333 

Buenaventura,  Colombia 97 

Buenos  Aires,  Nicaragua 192 

Bull,  Dr.  C.  G 197 

BuLLARD,  Texas 188 

BuRREs,  Dr.  W.  T 93 

BuTTRicK,  Wallace x,  xi,  79,  80,  81,  88 

Cairo,  Egypt 68 

Caius,  J.  F 160 

Calcutta 68 

415 


PAGE 

Caldwell,  Dr.  B.  W 92,  203 

Caldwell,  Dr.  F.  C 90, 142, 181 

Calhoun  County,  Alabama 192 

Callao,  Peru 96, 97, 100 

Campeche,  Mexico 105 

Canada: 

Fellowships 146 

Also 40,  326-327,  331,  334 

Canal  Zone 53,133 

Cannanore  Jail,  Madras 161, 165 

Canton  Christian  College 293,  295 

Canton  Hospital 299 

Carbon  Tetrachloride 142 

Carnatic  Mills  (Madras) 161, 165-166 

Carnegie  Nutrition  Laboratories 32 

Carter,  Dr.  H.  R 91 

Carter,  Dr.  W.  S note  324 

Cavell-Depage  Memorial  School  of  Nursing,  Brussels 36, 47 

Central  America 8,  49,  52,  53, 62,  70, 92, 96, 100, 106, 109, 133, 152 

See  also  Names  of  countries. 
Ceylon: 

Public  Health  Policy 136 

Fellowships 146 

Also 62, 90, 93, 184,  323 

Chagas,  Dr.  Carlos 153,  335 

Changsha,  China 68 

Charleville-Dalby  Area,  Queensland 166, 169 

Chen,  Dr.  S.  P 276,  280 

Chenopodium,  see  Oil  of  Chenopodium, 

Chickens  as  Carriers  of  Hookworm  Disease 176 

Children: 

Hookworm  Surveys  Among  Children  in  Southern  States    60-61, 

122-125 

Percentage  of  Hookworm  Infection  in  Queensland 169 

Hookworm  Infection  Rates  in  Siam 170-171 

Hookworm  Infection  Rates  in  Jamaica 173 

Dosage  of  Quinine  in  Malaria  Control 194 

Nutritional  Work  in  Schools 211-212 

Scarlet  Fever  at  Santa  Fe,  New  Mexico 214 

See  also  Hemoglobin. 
China: 

Progress  of  Medicine 250-251 

Study  in  Progress  of  Christian  Education 295 

416 


PAG& 

China — Continued 
Establishment  of  Terminology  Commission  by  Ministry  of 

Education 304 

Plans  for  Organization  of  National  Health  Association  . .  .     308 

Also 7, 40, 48, 93,  315,  317 

China  Christian  Educational  Association 306 

China  Medical  Board: 

Summary  of  Activities 46,  247-251 

Fellowships  and  Scholarships 51,  249-250,  301-303 

Officers  and  Members 81 

Aid  to  Medical  Schools 248,  281-286,  289-293 

Policy  in  Regard  to  Mission  Hospitals 248-249 

Grants  in  Aid  of  Translation  and  Terminology  Work  .  .  249,  304 
Reorganization  and  Equipment  of  Peking  Union  Medical 

College 252-281 

Annual  Contribution  to  Hunan- Yale  College  of  Medicine     284 
Appropriations  to  Shantung  Christian  University  School 

OF  Medicine 289-290 

Aid  TO  Pennsylvania  Medical  School  of  St.  John's  Univer- 
sity       291 

Co-operation  with  Chinese  Institutions 291-293 

Grant  to  National  Medical  College,  Peking 291-292 

Scholarship  Grant  to  University  of  Hong  Kong 293 

Surveys  of  Pre-Medical  Education 294-296 

Aid  to  Hospitals 297-301 

Assistance  to  Council  on  Hospital  Administration,  China    305 
Appropriation  to  North  China  Union  Language  School  .  .  .     305 

Appropriation  for  Emergency  Sanitary  Work 306 

China  Medical  Missionary  Association: 

Council  on  Medical  Education 286 

Grants  by  China  Medical  Board 304 

Council  on  Hospital  Administration 305 

Also 306 

Chingleput  Town  Reformatory,  Madras 165 

Cholera: 

Campaign  of  Education  in  Foochow,  China 307 

Choyce,  Dr.  C.  C 335 

Chulalonghorn  University,  Bangkok 320 

Clarke,  J.  L 91 

Clermont,  Queensland 169 

Clinics,  see  Commission  for  Prevention  of  Tuberculosis  in 

France;  Cornell  University  Medical  School. 
Cloncurry-Hughenden  Area,  Queensland 166 

417 


PAGE 

CoiMBATORE  (DiSTRICt)  MaDRAS 161 

CoiMBATORE  JaIL,  MaDRAS 165 

College  of  Medicine  and  Surgery  of  the  University  of  the 
Philippines,  see  University  of  the  Philippines — College 
OF  Medicine  and  Surgery. 

College  of  Yale-in-China 284 

See  also  Hunan- Yale  College  of  Medicine. 

Cologne,  Germany 333 

Colombia: 

Fellowships 146 

Percentage  of  Hookworm  Infection 172 

Also , ....  53, 90, 107, 142 

See  also  Buenaventura,  Colombia. 
Columbia  University,  New  York  City: 

Plans  for  New  Medical  School 7, 46^7,  326 

CoMiTE  National 66 

Commission  for  Prevention  of  Tuberculosis  in  France: 

Transfer  to  French  Agencies 8,  64 

Clinics  and  Dispensaries 64-65 

Training  Schools  and  Scholarships 65 

Educational  Propaganda 65-66 

Results  and  Cost  of  Administration 66-67 

Resume  of  Work 116, 119-120 

Dispensaries  and  Sanatoria 119-120 

Expenditures 230-231,  238-239 

Commissions  to  Medical  Centers 333-336 

Commonwealth  Fund: 

Contributions  to  Hunan- Yale  College  of  Medicine 284 

Concilium  Bibliographicum,  Zurich 68-69 

Connor,  Dr.  M.  E 53, 92, 104, 156,  203 

Constantinople 48, 68 

Contributions  from  the  Peking  Union  Medical  College,  Peking,  China     259 
Cornell  University  Medical  School: 

Work  of  the  Pay  Clinic 38-39 

Also 7 

Cort,  Dr.  W.  W 130, 140, 142, 143, 156, 160, 175, 180 

COSAMALOAPAN,  MeXICO 105 

Costa  Rica: 
Work  of  Hookworm  Control  Assumed  by  Government  . .  .  133-134 

Fellowships 146 

Also 24,  55, 90, 142 

Council  on  Public  Health  Education,  China,  see  Joint  Council 
ON  Public  Health  Education,  China. 
418 


PAGE 

County  Health  Work: 

General  Development 62 

Cost  of  Administration 63 

Malaria  Control 112, 115, 191-192 

Development  of  Organization  in  Brazil 129-130 

Development  of  Departments  in  Southern  States 149 

Personnel  and  Budgets 150,  208 

Experiment  in  County  Health  Administration,  Washing- 
ton County,  Maryland 150-151 

Field  Investigations  in  Southern  States 206 

Appropriations  for  Co-operative  Projects 206-207 

Plan  of  Work 207-208 

Public  Health  Nurses 208,  211 

Newer  Activities 211-112 

Nutritional  Work  in  Schools 211-112 

Results  of  Co-operative  Projects 212-214 

Table  Showing  Annual  Increase  in  Funds 215 

Stimulates  Interest  in  Foreign  Countries 215 

Expenditures 230-231,  236-237 

Covington,  Dr.  P.  W 90, 91 

CowDRY,  Dr.  E.  V 309 

Cracow,  Poland 333 

Cross,  H.  B 55-57 

Crossett,  Arkansas 191 

Crowell,  F.  E 92 

Cuba 53 

Culex  (Mosquito) 187 

Czechoslovakia  : 

Fellowships 146 

Commission  to  Study  Public  Health  Administration  .  .  .154-155 

Plans  and  Procedures  of  the  Ministry  of  Health 154-155 

Also 7,  34, 93, 95, 144, 150,  215,  333 

Dahomey,  Africa 108 

Dalby,  Queensland,  see  Charleville-Dalby  Area,    Queens- 
land. 

Dalhousie  University,  Halifax,  Nova  Scotia 47,  326,  337 

Darjeeling  (District)  Bengal 161 

Darling,  Dr.  S.  T 93, 140, 156 

Darwin,  Northern  Territory 166 

Dashiell,  L.  M 80 

Davies,  Dr.  W.  H 92 

Daviess  County,  Kentucky 212-213 

419 


PAGE 

Davis,  J.  W xi,  79 

DeBoard,  Ollie 56 

Dermott,  Arkansas 191 

Dershimer,  Dr.  F.  W 90 

Detwiler,  S.  R 310 

Devarshola  Estate,  Madras 165 

De  Waart,  Dr.  a 280 

Dewin,  J.  B 336 

DiNDiGUL,  Madras 161, 163 

Diphtheria 29,  211,  212-213 

Dispensaries 136, 154 

See  also  Commission  for  Prevention  of  Tuberculosis  in 
France. 
Division   of   Medical   Education,   see   Medical    Education, 
Division  of. 

Docherty,  Dr.  J.  F 91 

Dogs,  see  Animals. 

DuNLAP,  Dr.  A.  M 309 

Dutch  Guiana: 

Government  Support  of  Public  Health 132 

Percentage  of  Hookworm  Infection 172 

Also 90, 130 

Dysentery 124, 125 

DzEN,  T.  T 310 

Ecuador 53,  55, 97, 100,  203 

See  also  Guayaquil,  Ecuador. 

Eggleston,  M.  K 81 

Egypt: 

Government  Resuming  Operations 139 

Also 48 

Elmendorf,  Dr.  J.  E.,  Jr 90 

Embree,  E.  R X,  xi,  79,  80,  81,  88 

Embrey,  H.  C.  . . . ! 308,  309 

Emerald,  Queensland,  see  Longreach-Emerald  Area,  Queens- 
land. 

England 40,  95, 96,  331-332,  334 

EspiRiTO  Santo,  Brazil 89, 121 

Eure-et-Loir,  France 63 

Europe: 

Medical  Centers  Supplied  with  Medical  Journals 48 

Temporary  Aid  to  Universities  of  Central  Europe  .  .48,  332-333 
Also 49,  3 1 5 

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PAGE 

Far  East: 

Promotion  of  Public  Health 135-139 

Surveys  of  Medical  Education 315-320,  323-325 

Also 49 

See  also  Names  of  places. 

Farmville,  North  Carolina 211 

Faust,  E.  C 308,  309. 3 10 

Federal  District,  Brazil: 

Resurveys  for  Hookworm  Infection 127-129 

New  Health  Divisions 153 

Federated  Malay  States 320 

Fellowships  and  Scholarships: 

For  Polish  Nurses 37 

Grouping,  and  Distribution  by  Country 50-51 

Increase  and  Supervision 51-52 

For  Tuberculosis  Work  in  France 65 

ForGraduate  Students  at  Peking  Union  Medical  College  261-262 

To  University  of  Hong  Kong  Medical  School 293 

Grants  by  China  Medical  Board 301-302 

Gratifying  Results  of  China  Medical  Board  Fellowships  302-303 

Plan  for  Medical  Teachers  in  the  United  States 337 

Also 8, 145-146,  249-250,  336-337 

Ferrell,  Dr.  J.  a 81,  89, 156 

Field,  H.  H 69 

Fiji  Islands: 

Progress  of  Public  Health  Work 135 

Fish: 

In  Yellow  Fever  Control 99-100, 104,  200,  203-204 

Top  Minnows  in  Malaria  Control 110, 115,  116, 187, 192, 

197-198,  200,  204 

Family  Poeciliidae 203-204,  205 

Fisher,  Dr.  A.  C 124 

Fletcher,  Sir  Walter 335 

Flexner,  Dr.  Simon x,  xi,  79,  80,  81,  88,  253 

Florida 150,  207 

FoocHow 307 

See  also  Fukien  Christian  University,  Foochow. 

FosDicK,  R.  B X,  xi,  79,  80,  81,  88 

France 40, 92, 95, 96, 146,  215,  324,  328,  331,  333 

See  also  Commission  for  Prevention  of  Tuberculosis  in 
France. 

Frankfort,  Germany 333 

Free  University  of  Brussels 7, 47,  50,  331,  337 

421 
26 


/ 

PAGE 

Freiburg,  Germany 333 

FuKiEN  Christian  University,  Foochow 295 

Gage,E.H 91 

Gamhusia  aflnis  (Top  Minnow),  see  Fish. 

Gametes  (in  Blood) 197 

Gann,  Dr.  Thomas 139-140, 171 

Gates,  Dr.  F.  L 81 

Gates,  F.  T x,  xi,  79,  80,  88 

Geary  County,  Kansas 213 

Geiger,  Dr.  J.  C 200 

General  Education  Board 326,  331,  337 

Genoa,  Italy 333 

Georgia 146,  150,  187,  197,  note  207,  214 

See  also  Augusta,  Georgia. 

German  Medical  School,  Shanghai .' 292 

German  New  Guinea,  see  Late  German  New  Guinea. 

Germany 333 

Ghent,  Belgium 333 

Gilbert,  F.  P 91 

GiNLiNG  College  for  Women,  Nanking 295 

Gladstell,  Texas 191 

Gold  Coast 108 

Goldwater,  Dr.  S.  S 279 

GooDNow,  F.  J 81 

Goossens-Bara,  Armand 334 

GoRGAs,  Sur.-Gen.  W.  C 53, 97 

Gottingen,  Germany 333 

Governor's  Island,  Brazil 180 

Grant,  Dr.  J.  B 93,  308 

Gratz,  Austria 332 

Great  Britain 8 

Green,  H.  W 91 

Greene,  R.  S xl,  81 

Greenville,  North  Carolina 211 

Greenwood  County,  South  Carolina 212 

Gregg,  Dr.  Alan 89, 157 

Greifswald,  Germany 333 

Grogan,  G.  L 188 

Guatemala 55, 90, 92, 103, 104, 106, 146, 153,  204 

Guayaquil,  Ecuador 53, 97, 99, 100, 104, 108,  200 

GuiTERAs,  Dr.  Juan 92, 157 

Gunn,  S.  M 93 

422 


PAGE 

Hackett,  Dr.  L.  W ......89,93,157,171 

Halifax,  Nova  Scotia,  see  Dalhousie  University,  Halifax, 
Nova   Scotia;   Salvation  Army,   Halifax,   Nova  Scotia. 

Hall,  Dr.  M.  C 142 

Hamburg,  Arkansas 191 

Hamburg,  Germany 333 

Hammond  Island,  Queensland 169 

Hampton,  Dr.  G.  G 90 

Han,  C.  H 309 

Hanover,  Germany 333 

Hanson,  Dr.  Henry 99, 109,  200,  203 

Harlan  County,  Kentucky 212-213 

Harrison,  Dr.  A.  P 91, 157 

Harvard  University: 

Work  of  the  Medical  School 29-31 

Contributions  to  New  School  of  Public  Health 7,  31, 145 

Hastings,  L.  G 91 

Hata,  Dr.  S 279 

Haughwout,  Dr.  F.  G 280 

Hausheer,  Dr.  W.  C 90 

Havana 53, 96 

Health  Officers'  Training  Courses 146 

Health  Societies,  see  National  Health  Council. 

Hegner,  R.  W 157 

Heidelberg,  Germany 333 

Heiser,  Dr.  V.  G 81,  89, 93, 139 

Hemoglobin: 

Average  Index  Among  Prisoners  in  Madras  Jails 165 

Average  Index  Among  Coolies 165, 166 

Average  Index  in  Papua 170 

Index  Among  Children  in  Siam 171 

Index  Among  Children  in  Jamaica 173 

Hepburn,  A.  B x,  xi,  79 

Herringham,  Sir  Wilmot 334-335 

HiLDEBRAND,  S.  F 200 

Hill,  Dr.  R.  B 90 

Hinds  County,  Mississippi 200 

Honduras 55,  92, 103, 104, 106, 121 

Hong  Kong: 

Medical  Education 315,  316-317 

Also 40, 48,  68 

See  also  University  of  Hong  Kong. 

423 


fAGfe 

Hookworm  Disease,  Diagnosis: 

Stool  Examination  Technique 141 

Willis  Salt-Flotation  Method 142, 184 

Lane  Levitation  Method 184-185 

Differentiation  of  Hookworm  and  Strongyloid  Larvae  . . .     142, 

185-186 

Hookworm  Disease,  Infection: 

Rates  in  Jamaica 132, 172-173 

Rates  in  Madras  Presidency 161-166 

Affected  by  Jail  Life 164 

Hemoglobin  Indices 164, 165, 166, 170, 171, 173 

Incidence  in  Australia 166, 169-170 

Among  Children  in  Queensland 169 

Rates  in  Papua 169-170 

Rates  in  Siam 170-171 

Rates  Among  Prisoners  in  Siam 171 

Rates  in  Dutch  Guiana 172 

Rates  in  Porto  Rico 172 

Rates  in  Colombia 172 

Pigs  and  Chickens  as  Carriers 176 

Epidemiologic  Study  in  Trinidad  . 176, 179 

Among  the  San  Blas  Indians 181-182 

Severity  Estimated  by  Counting  Ova  in  Microscopic  Field  .  .     185 

Hookworm  Disease,  Relief  and  Control: 

In  Richmond  County,  Virginia 60-61,  122-124 

Resurveys  in  Southern  States 61-62 

Work  of  Board  in  Southern  States  Completed 62, 126-127 

Relation  to  County  Health  Work 62, 149 

Resurveys 124-126,  214 

Resurvey  in  Brazil 127-129 

Government  Appropriation  in  Panama 133 

Government  Control  in  Central  America 133-135 

Government  Aid  in  the  Far  East 135-136 

Miscellaneous  Government  and  Voluntary  Effort 139-140 

Field  Studies 141-143 

In  Madras  Presidency 161-166 

Results  in  Sumatra 173-174 

Economy  in  Field  Operations 180 

Simplified  Plan  of  Procedure 180-181 

Tables  Showing  Examinations  and  Treatments 218-228 

Expenditures 230-235 

Also 8 

424 


PAGE 

Hookworm  Disease,  Treatment: 

Value  of  Mass  Treatment 140-141 

Further  Tests  with  Anthelmintics 141-142 

Carbon  Tetrachloride  given  to  Dogs 142 

Results  in  Jamaica 172-173 

Plans  for  Heavily  and  Lightly  Infected  Areas 180-181 

Mass  Treatment  in  Absence  of  Latrines 181 

See  also  Names  of  drugs. 
Hookworms: 
Studies  on  Eggs  and  Larvae  in  the  Soil  ...  29, 142, 175-176, 179-183 
Modified  Baermann  Apparatus  for  Recovery  of  Larvae 

FROM  the  Soil 142, 182-183 

Action  of  Sea- Water  on  Eggs  and  Larvae 142-143 

Differentiation  of  Hookworm  and  Strongyloid  Larvae  . .  .     142, 

185-186 

Necator  suillus 176 

Negators  {Necator  americanus) 162, 163 

Migration  of  Larvae  in  Soil 179 

Position  of  Larvae  in  Soil 179-180 

Effect  of  Salt  on  Viability  of  Eggs  and  Larvae 181-182 

Hospital  Library  and  Service  Bureau,  Chicago 69 

Houghton,  Dr.  H.  S 81,  254,  279,  305,  325 

Howard,  Dr.  H.  H 81,  89, 93, 115,  200 

Howard  B.  Cross  Laboratory,  Vera  Cruz 56 

Hughenden,   Queensland,   see  Cloncurry-Hughenden  Area, 
Queensland. 

Hughes,  C.  E x 

HuLSE,  F.  E 91 

Hunan- Yale  College  of  AIedicine 282-285 

Hungary 333 

Hydrick,  Dr.  J.  L 93 

Impounding  of  Water,  see  Malaria  Control. 

India 7, 49,  62,  90, 141, 142,  200,  317,  323 

See  also  Names  of  places. 

Indian  Research  Fund  Association note  141, 161 

Indiana 90,  207 

Indo  China: 

Medical  Education. 315,  323-324 

Also 7, 48, 68,  328 

Innsbruck,  Austria 332 

International  Health  Board: 
Establishment  of  School  of  Hygiene  and  Public  Health  at 
Johns  Hopkins  University 22-23 

425 


PAGE 

International  Health  Board — Continued 

Funds  for  Institute  Teaching 33 

Co-operation  with  Ministry  of  Health  of  Czechoslovakia       34 
Contribution  to  Department  of  Hygiene  at  Sao  Paulo, 

Brazil 34 

Co-operation  with  British  Ministry  of  Health 35 

Courses  for  New  York  State  Nurse  Training 36 

Nurse  Training  Centers  in  France 36 

Public  Health  Nursing  Service  in  Brazil 36-37 

Fellowships 51, 145-146 

Co-operation  with  Mexican  Government  in  Yellow  Fever 

Control 54 

Work  and  Death  of  H.  B,  Cross 55-57 

Malaria  Control 57-60 

Hookworm  Surveys  of  School  Children  in  Virginia 60-61 

Resurveys  in  Southern  States 61-62 

County  Health  Work 62-63, 149-151, 206-215 

Tuberculosis  Campaign  in  France 64-67, 116, 119-120 

Limitation  to  Activities  in  Tuberculosis  Control ^6 

Visits  to  Medical  Schools 68 

Officers  and  Members 80-81 

Survey  of  Activities 95 

Yellow  Fever  Control 95-109,  200,  203-204 

Malaria  Control 109-116, 187-199 

Hookworm  Control 120-127, 161-186 

Termination  of  Hookworm  Work  in  Southern  States  ....  126-127 

Rural  Sanitation  in  Brazil 129 

Sanitation  in  West  Indies 130-133 

Public  Health  in  Central  America 133-135 

Work  in  the  Far  East 135-139, 170-171, 173-174 

Modification  in  Field  Procedures 140-141 

Development  of  Schools  of  Hygiene 143-145 

Extension  Courses  in  Public  Health 146 

Contributions  to  County  Health  Budgets 150 

Public  Health  Laboratories 151-153 

Assistance  to  Nurses'  Training  School  in  Rio  de  Janeiro  153-154 

Institute  of  Public  Health  at  Prague 154-155 

Reports  and  Publications  Issued 155-158 

Field  Operations 180-181 

Anti-Mosquito  Measures 187-193, 200-205 

Statistical  Tables 216-228 

Expenditures 230-241 

Staff  Member  Assigned  to  Peking  Union  Medical  College    308 

426 


PAGE 

International  Health  Board — Continued 

Co-operation    in    Public    Health    Work    in    Philippine 

Islands 324-325 

Also 8,  21,  24, 28 

Investigation  on  the  Control  of  Hookworm  Disease,  by  W.  W.  Cort, 

D.  L.  Augustine,  J.  E.  Ackert,  F.  K.  Payne,  and  G.  C. 

Payne 160 

Iquitos,  Peru,  see  Yquitos,  Peru. 

Ireland 40 

Italy 96,  333 

Jacarepagua,  Brazil 180 

Jacocks,  Dr.  W.  P 90 

Jails  and  Penitentiaries,  see  Cannanore  Jail,  Madras;  Coim- 
BATORE  Jail,  Madras;  Hookworm  Disease,  Infection; 
Parchman  Penitentiary,  Sunflower  County,  Mississippi; 
Trichinopoly  Jail,  Madras. 

Jalap  Powder 142 

Jamaica: 

Popular  Interest  in  Public  Health 132 

Appointment  of  Health  Officer 132-133 

Average  Hookworm  Infection  Rates 172-173 

Also 90, 122, 130, 142 

Janney,  Dr.  J.  H 89, 92, 93 

Japan: 

Medical  Education 315-316 

Also 7, 40, 48, 68 

Java 40, 48 

Jena,  Germany 333 

Jenner,  Dr.  Edward 10 

JoANNOviTCH,  Dr.  Georges 335 

Johns  Hopkins  University — School  of  Hygiene  and  Public 
Health: 

Faculty,  Students,  and  Courses 23-24 

Aim  and  Scope 24,  27 

Field  Laboratory 28 

Investigative  Work 28-29 

New  Building  and  Equipment 29 

Also 7,  93, 144, 150, 175 

Johnson,  E.  B 91 

Johnson,  H.  A 91, 93 

Joint  Council  on  Public  Health  Education,  China 306-307 

Jordan,  E.  O 80,  88 

427 


PAGE 

Journal  of  Industrial  Hygiene 31 

Journal  oj  the  American  Medical  Association,  Spanish  edition 70 

JuDSON,  H.  P X,  xi,  79,  81 

Jugoslavia,  see  Serbs,  Croats,  and  Slovenes,  Kingdom  of. 

Kalyanapandal  Tea  Estate,  Madras 161 

Kansas 90,  150,  note  207 

See  also  Geary  County,  Kansas. 

Kellogg,  Vernon xi,  79,  80,  81 

Kendrick,  Dr.  J.  F 90, 141, 160, 161 

Kentucky 90,  150,  note  207,  212,  214 

See  also  Names  of  counties. 

Kiel,  Germany 333 

King  Edward  VII  Medical  School,  Singapore 320,  323 

Kirk,  R.  H x,  xi,  81 

Kligler,  I.  J 157 

Klotz,  Dr.  Oskar 328 

KoRNs,  Dr.  J.  H 309,  310 

Kuling,  China 263 

Laboratories: 

Relation  to  Public  Health  Administration 151 

In  Europe 152 

In  Southern  States 152 

In  Central  America 152-153 

Laboratory  Technique,  see  Hookworm  Disease,  Diagnosis. 

Lake  Charles,  Louisiana 188 

Lake  Village,  Arkansas *. 191 

Lambayeque  (Department)  Peru 98 

Lambayeque  (Town)  Peru 109 

Lambert,  Dr.  S.  M 89, 90, 157, 169 

Lampang,  Siam 170 

Lane,  Col.  Sir  Clayton 139, 141, 161, 184, 185 

Lane  Levitation  Method,  see  Hookworm  Disease,  Diagnosis. 

Lanza,  Dr.  A.  J 92, 136 

La  Puebla-Rivas,  Nicaragua 192-193,  203-204 

Late  German  New  Guinea 89, 121 

Latrines: 

In  Richmond  County,  Virginia 123-124 

In  Federal  District,  Brazil 127-129 

In  Trinidad 131 

In  Fiji  Islands 135 

In  British  Honduras 140, 171 

428 


PAGE 

Latrines — Continued 

In  Southern  States 206,  212 

Also 180, 181 

Laurens,  H 310 

Lazear,  Dr.  Jesse 55 

Leach,  Dr.  C.  N 89, 90, 93 

League  of  Nations — Health  Committee 73 

League  of  Red  Cross  Societies 73 

Leiper,  Dr.  R.  T 279 

Leipsig,  Germany 333 

Le  Prince,  J.  A 157,  203 

Leptospira  icteroides  (Yellow  Fever  Bacilli) 108 

LiBERTAD,  Peru 98,  100 

LiEN-TEH,  Dr.  Wu 280 

Lille,  France 328 

Lima,  Peru 203 

Lionel  Town  Hospital,  Jamaica 172 

Lister,  Dr.  Joseph 10 

London 334 

See  also  University  College  Hospital  Medical  School, 
London;  University  of  London. 

Longley,  F.  F 92, 136 

Longreach-Emerald  Area,  Queensland 166, 169 

Lonoke,  Arkansas 200 

Louisiana 91, 150, 187, 207 

See  also  Lake  Charles,  Louisiana;  Mound,  Louisiana. 

Lower  Para  (Dutch  Guiana) 132 

Lower  Surinam  (Dutch  Guiana) 132 

Lwow,  Poland 333 

Lyons,  France 152,  333 

Lyster,  Dr.  T.  C 92 

McGiLL  University,  Montreal 47,  326 

McKay,  Dr.  A.  L 90 

McLean,  Dr.  F.  C 254 

Macallum,  Dr.  a.  B 258, 279 

Madras  (City)  India: 

Percentage  of  Hookworm  Infection 161-162, 165-166 

Madras  (Presidency)  India: 

Government  Aid  in  Hookworm  Control 135-136 

Campaign  Against  Hookworm  Disease 161 

Percentage  of  Hookworm  Infection 161-166 

Madura,  Madras 163 

429 


Magoon,  E.  H 91 

Maharat,  Siam 170 

Malabar,  Madras 163, 165 

Malaria  Control: 

RisuME  OF  Operations 57-60 

Per  Capita  Cost 59,  110 

Use  of  Fish  as  Anti-Mosquito  Measure 59-60, 200,  204-205 

Surveys  in  the  South 60 

Results  of  Field  Experiments 109-110 

Use  of  Top  Minnow 110, 115, 116, 187, 192, 197-198,  200-204 

State  Budgets 110-111 

Intensive  Demonstrations  and  Municipal  Governments.  . .     112 

County  as  Unit  of  Operations 112, 115 

Quinine  Treatment 112, 115-116 

Field  Experiments  Continued 115-116 

Tests  in  Screening  of  Houses 116 

Mosquito  Control  in  Nicaragua  and  Porto  Rico 116 

In  Trinidad 131 

Results  and  Costs 187-188 

Anti-Mosquito  Measures  in  Southern  States 187-188, 191 

Economic  Value 188 

Legislative  Appropriations 191 

In  Arkansas 191 

In  Alabama 191-192 

Work  of  County  Health  Departments 191-192,  211 

Cost  of  Fish  Control 192 

Anti-Mosquito  Measures  under  Tropical  Conditions  . . .  192-193 
Results  and  Per  Capita  Cost  in  La  Puebla-Rivas  Nicara- 
gua      193 

Sterilization  of  Carriers 193-197 

Determining  Carriers 197 

Field  Studies  at  Mound,  Louisiana 197-198 

By  Impounding  Water  in  Bayous 198 

Survey  in  Missouri 199 

Use  of  Fish  in  Rivas,  Nicaragua 203-204 

Use  of  Fish  in  Southern  States 204 

Expenditures 230-231,  236-239 

Also 8 

See  also  Fish;  Quinine. 

Managua,  Nicaragua 203 

Manantoddy  Estate,  Madras 165 

Manchuria 68 

Manila 317 

430 


PAGB 

Manila  General  Hospital 324 

Manzanillo,  Mexico 106 

Marburg,  Germany 333 

Marine  Biological  Laboratory,  Woods  Hole,  Massachusetts      68 

Marshall,  Dr.  H.  K 92 

Maryland 150,  207 

See  also  Washington  County,  Maryland. 

Maryland  State  Board  of  Health 27,  28, 150 

Mass  Treatment,  see  Hookworm  Disease,  Treatment. 

Massachusetts  Institute  of  Technology 30-31 

Mauritius  : 

Government  Control  in  Hookworm  Measures 121, 135 

Maxwell,  Dr.  J.  P 309,  310 

Maya  Cities,  Yucatan 103 

Mazatlan,  Mexico 96, 103, 106 

Medical  Education: 

Summary  of  Expenditures 82 

In  China 252-293 

Surveys  in  the  Far  East 315-317,  319-320,  323-325 

Medical  Education,  Division  of: 

Aid  to  Medical  Schools  in  Canada 47,  326-327 

Main  Activities  Summarized 315 

Surveys  in  the  Far  East 315-317,  319-320,  323-325 

Work  in  United  States 326 

Development  of  Department  of  Pathology  at  Sao  Paulo 

Medical  School 327-328 

Aid  to  Pasteur  Institute,  Paris 328-329 

Aid  to  Free  University  of  Brussels 331 

Final  Contracts  for  Medical  School  in  London 331-332 

Supplying  Medical  Journals  and  Equipment  to  European 

Universities 332-333 

Commissions  to  Medical  Centers . .  .  333-336 

Fellowships 336-337 

Also 8,  301,  324 

Medical  Research  Council  (English  Privy  Council) 50,  335 

Merida,  Yucatan 100, 103, 105, 203 

Methodist  Hospital,  Peking 299 

Mexico: 

Fellowships 146 

Also 8,  52,  54, 70, 92, 93, 96, 100, 103, 104, 106, 108, 152, 153 

iS^^  also  Names  of  towns  and  states 

Meyer,  E.  C 155 

Mhaskar,  Dr.  K.  S 141, 160, 185 

431 


PAGE 

Michigan 146 

MiELDAZIS,  J.  J 91,93 

Migration  of  Hookworm  Larvae,  see  Hookworms. 

Milk  Supply 212 

Miller,  Dr.  F.  A 90 

MiNAS  Geraes  (State)  Brazil 215 

Mission  Hospital  Account  Books 305 

Mission  Hospitals  in  China: 

Policy  of  China  Medical  Board 248-249 

Important  Educational  Functions 297-298 

Grants  from  China  Medical  Board 298-299 

Mississippi: 

Malaria  Control  in  Bolivar  and  Sunflower  Counties  . .  .115-116 

Also 91,  111,  115,  150,  152,  187,  191,  197,  note  207 

See  also  Parchman  Penitentiary,  Sunflower  County,  Miss- 
issippi; RuLEViLLE,  Sunflower  County,  Mississippi; 
also  Names  of  counties. 

Mississippi  Department  of  Health 193 

Missouri: 

Malaria  Survey 60, 199 

Also 91,  111,  150, 191,  207 

Missouri  State  Board  of  Health 199 

Molloy,  Dr.  D.  M 90,  92, 142, 184,  203 

Monroe,  Paul: 

Investigation  of  Pre-Medical  Education  in  Chinese  and 

Foreign  Colleges 295 

Also 296 

Monroe,  Dr.  W.  M 92, 93 

Montgomery  County,  Tennessee 211,  212,  213 

Montpellier,  France 152 

Morgan  County,  Alabama 192 

Mosquito  Control,  see  Malaria  Control;  Yellow  Fever. 

MoTT,  J.  R 81 

Mound,  Louisiana: 

Studies  and  Experiments  in  Malaria  Control 116, 197 

MuDis  Tea  Estate,  Madras 161, 166 

MuENCH,  Dr.  Hugo,  Jr 91 

Mukden,  see  South  Manchuria  Medical  College,  Mukden. 

Munich,  Germany 333 

Murphy,  Starr  J x 

Myers,  L.  G x,  xi,  80 

432 


PAGE 

Nagayo,  Dr.  Mataro 279 

Nancy,  France 152 

Nanking,  China,  see  Ginling  College  for  Women,  Nanking. 

Naples,  Italy 333 

Natal,  Brazil 107 

National  Committee  for  Mental  Hygiene 13 

National  Educational  Reform  Association,  China 296 

National  Health  Council 22 

National  Malaria  Committee 197 

National  Medical  Association,  China: 

Grants  by  China  Medical  Board 304 

Also 291,  306 

National  Medical  College,  Peking 291,  292 

National  Research  Council: 

Fellowships 51 

Also 69,  336,  337 

Near  East 49 

Necators,  see  Hookworms. 

Negapatam,  Madras 161, 163 

New  Atlantis,  quoted 48-49 

New  Guinea,  see  Late  German  New  Guinea. 

New  Jersey  Agricultural  Experiment  Station 200 

New  Mexico 91,    105,  note  207 

S>ee  also  Santa  Fe,  New  Mexico. 

New  South  Wales 121, 166 

New  York  City 29 

See  also  Columbia  University,  New  York  City;  Presby- 
terian Hospital,  New  York  City. 

New  York  State 146 

New  York  State  Department  of  Health 32 

New  York  University: 

Appropriation  by  Rockefeller  Foundation 32-33 

Nicaragua: 

Tests  in  Mosquito  Control 116 

Establishment  of  National  Department  of  Health 134 

Fellowships 146 

Also 55,  59, 90, 91, 92, 103, 104, 106, 142, 152 

See  also  Names  of  towns. 
Nigeria,  see  Northern  Nigeria;  Southern  Nigeria. 

Nikolitch,  Dr.  G.  J 335 

Nilgiri  Tea  Estates  see  Wynaad-Nilgiri  Tea  Estates,  Madras. 
Noguchi,  Dr.  Hideyo 53,  54,  92, 108, 157 

433 


PAGE 

North  Carolina 91, 150, 187,  207,  214 

Sff  also  Farmville,  North  Carolina;  Greenville,  North  .    ^ 

Carolina;  Pitt  County  Health  Department,  North|  ,:"t'< 

Carolina. 

North  China  Union  Language  School 305 

Northern  Nigeria 108 

Northern  Territory,  Australia 121, 166 

Nurses,  see  Public  Health  Nurses. 

Nurses*  Training  Schools,  see  Public  Health  Nurses. 

O'Brien,  Dr.  H.  R 90, 93 

Ohio 146, 214 

Oil  in  Mosquito  Control 203 

Oil  of  Chenopodium 140, 142 

Oriente,  Salvador 204 

Oswaldo  Cruz  Institute,  Rio  de  Janeiro 50,  337 

Pa,  Dr.  T.  C 309 

Paijan,  Peru 109 

Panama  (City) 182 

Panama  (Republic): 

Government  Appropriation  for  Hookworm  Control 133 

Also 90, 97, 99, 142, 152 

Panjampatti,  Madras 163 

Papantla,  Mexico 105 

Papua 89, 169-170 

Para,  see  Lower  Par!  (Dutch  Guiana). 

Paraguay 93, 139 

Parchman  Penitentiary,  Sunflower  County,  Mississippi 194 

Pare; A,  Dr.  Wenceslao 97, 157 

Paris 64, 152, 333 

Parker,  George 91 

Parsons,  Ethel 92 

Pasteur,  Louis 10 

Pasteur  Institute,  Paris 7,  33,  328,  331 

Paul,  Dr.  G.  P 90, 161 

Payne,  Dr.  F.  K 160, 175 

Payne,  Dr.  G.  C 90, 130, 140, 156, 157, 160, 175 

Peabody,  Dr.  F.  W 81, 258, 279 

Pearce,  Dr.  R.  M x,  xi,  81, 254 

Peking 68 

See  also  Methodist  Hospital,  Peking;  National  Medical 
College,  Peking. 
Peking  Union  Medical  College: 
Formal  Opening 39-40,279 

434 


*AGfe 

Peking  Union  Medical  College — Continued 

Buildings 40, 43, 263-277 

Staff 43-44, 257 

Student  Registration 43-44,  261 

Aims  and  Problems 44, 247-248, 252-253 

Policy 45 

Public  Service  of  Faculty 45-46,  281 

Graduate  Work 249-250, 261-262 

Budget  for  1921-1922 253 

Visiting  Professorships 257-258 

Contributions  from  the  Peking  Union  Medical  College,  Peking,  China  259 

Requirements  for  Admission 259-260 

Course 261 

Charter 261 

Summer  Course  for  Doctors  at  Ruling 262-263 

Laboratories 266-267 

Residences  for  Staff  Members 275 

Mechanical  Equipment 277 

Library 277-278 

Dr.  John  B.  Grant  Assigned  to  Staff 308 

Publications  of  Staff  Members 308-310 

Also 7,  305;  315,  325 

Peking  Union  Medical  College,  Hospital: 

Training  School  for  Nurses  . ! 37, 278 

Buildings 267-268,  271-272 

Capacity 272 

Chinese  Appreciation 280-281 

Peking  Union  Medical  College,  Pre-Medical  School: 

Plans  for  Closing 294-295 

Investigation  by  W.  W.  Stifler  and  S.  D.  Wilson 296 

Also 275 

Peking  University 278 

Pennsylvania    Medical   School   of   St.   John's   University, 
Shanghai,  see  St.  John's  University,  Shanghai. 

Pernambuco  (City)  Brazil 107 

Pernambuco  (State)  Brazil 89 

Peru: 

Campaign  Against  Yellow  Fever 97-100,  200,  203 

Also 53, 55, 92, 109 

Petri  Dish 186 

Petritz,  Dr.  L.  J 91 

Philippine  Hospital  Ship: 
Expenditures 230-231 

435 


PAGE 

Philippine  Islands: 
Development  of  Medical  and  Public  Health  Resources  324-325 

Also 7, 40, 48, 68, 70, 93, 139,  315,  317 

See   also   University    of    the    Philippines — College    of 
Medicine  and  Surgery. 

Pi,  Dr.  H.  T 309 

Pigs,  see  Animals. 

Pitt  County  Health  Department,  North  Carolina 211 

Piura  (Department)  Peru 98, 100 

PoEciLiiDAE,  see  Fish. 

Poland: 

Fellowships 146 

Also 95,  333 

Porto  Calvo,  Brazil 107 

Porto  Rico: 

Field  Experiment  in  Mosquito  Control 116 

Government  Appropriation  for  Public  Health 131 

Appropriation  for  Tuberculosis  Sanatorium 131 

Also 24,  59, 90, 91, 130, 192 

See  also  Quebradillas,  Porto  Rico. 

Prague,  Czechoslovakia 34,  333 

Prague  Institute  of  Hygiene 144, 152, 155 

Pre-Medical  Education: 

Investigations  in  China ! 294-296 

Presbyterian  Hospital,  New  York  City 46 

Preventive  Medicine 10-14 

Princes  Town,  Trinidad 175 

Prudden,  Dr.  T.  M 80,  88 

Public  Health: 

Summary  of  Expenditures 82 

Public  Health  Education: 

Extension  Courses 146 

Expenditures 230-231,  238-241 

In  China 306-308 

See  also  Joint   Council   on    Public   Health    Education, 
China;  Schools  of  Hygiene. 

Public  Health  Laboratory  Service: 

Expenditures 230-231,  240-241 

Also 89 

Public  Health  Nurses: 

Training  Centers  in  France 36 

Surveys 36,  37 

Government  Training  School  in  Rio  de  Janeiro 153-154 

436 


PAGE 

Public  Health  Nurses — Continued 
In  County  Health  Work 208-211 

Public  Health  Nurses'  Institutes 146 

Public  Health  Work: 

Demand  for  Trained  Leadership 15-18 

Handicaps  to  Recruiting 18-20 

Responsibility  of  the  Public 20-22 

Publications  by  Staff  Members: 

International  Health  Board v  . .  .    .  ^ 155-158 

Peking  Union  Medical  College 308-310 

Puerto  Obaldia,  Panama 182 

Purgatives,  see  Names  of  Drugs. 

QUEBRADILLAS,  PoRTO  RiCO 172 

Qveensland: 

Hookworm  Infection  Survey 166, 169 

Akso 121, 184 

See  also  Names  of  places. 

Quinine: 

Experimental  Studies  in  Mississippi 193-194 

Development  of  Standard  Treatment  for  Malarla 194 

Dosage  for  Adults  and  Children  , 194-19$ 

Prophylactic  Treatment 195 

Demonstration  Campaign 195-196 

Discontinuance  of  Free  Distribution 195, 196 

Per  Capita  Cost 196 

Standard  Quinine  Packets 196-197 

Also 57, 59 

Quitman  County,  Mississippi 194 

Read,  F.  M 80, 88 

Rector,  N.  H 91, 93 

Red  Cross,  see  American  Red  Cross;  Siam. 

Reed,  Dr.  Walter 53, 96, 97 

Report  Covering  Experiments  in  Malaria  Control,  by  C.  C.  Bass 160 

Results  of  Hookworm  Disease  Prophylaxis  in  Bra%il,   by  W.  G. 

Smillie note   129,   note   141,   note   180 

Rice,  Dr.  J.  L 90 

Richmond,  Virginia 204 

Richmond  County,  Virginia: 

Hookworm  Surveys 122-124 

Rio  Cobre  Home,  Jamaica 173 

Rio  de  Janeiro  (City)  Brazil .96, 107, 153 

437 
27 


PAGR 

Rio  de  Janeiro  (State)  Brazil 53,  89, 129,  215 

Rio  Grande  do  Sul  (State)  Brazil 89,  215 

RivAS  (Department)  Nicaragua 203-204 

See  also  La  Puebla-Rivas,  Nicaragua. 

Roane  County,  Tennessee 212 

Rockefeller,  J.  D x,  xi,  79 

Rockefeller,  J.  D.  Jr x,  xi,  79,  80,  81,  88 

Rockefeller  Foundation: 

Resume  of  Activities 7-8 

Contribution  to  National  Committee  for  Mental  Hygiene      13 

Contribution  to  National  Health  Council 22 

Support  of  School  of  Hygiene  and  Public  Health,  Johns 

Hopkins  Univ ersity 23,  29 

Pledges  and  Appropriations  to  Harvard  School  of  Public 

Health 31, 144-145 

Appropriation  to  New  York  University 32-33 

Gifts  and  Pledges  to  Pasteur  Institute,  Paris 33,  328,  331 

Pledge  to  Prague  Institute  of  Hygiene 34 

Survey  of  Public  Health  Nursing 36 

Fellowships  and  Scholarships 37,  50-52,  336-337 

Cornell  Pay  Clinic 38-39 

Appropriation  for  New  Medical  School  in  New  York  City.  .  46-47 
Pledges  to  Medical  School  of  Free  University  of  Brussels 

47,331 

Aid  to  Medical  Schools  in  Canada » 47,  326-327 

Aid  to  Medical  Centers  and  Universities  in  Europe.  .  .48,  332-333 

Commissions  to  Medical  Centers 48-50,  333-336 

Progress  of  Yellow  Fever  Control 52-55 

Consultation  Services  and  Field  Studies 67-68 

Sundry  Items  of  Aid  and  Service 68-70 

Applications  for  Aid  Received  and  Acted  Upon 71 

Finances,  with  Table  Showing  Receipts  and  Disburse-, 

MENTS 71-72 

Report  of  Secretary 79-84 

Members  and  Officers .-79-80 

Regular   Meetings   and   Meetings   of   Executive   Com- 
mittee         80 

Departmental  Agencies 80-81 

Work  with  Unaffiliated  Organizations :  81-82 

Expenditures  for  Public  Health,  Medical  Education, 

Miscellaneous  and  Administration 82-83 

Funds  and  Property 83-84 

438 


Rockefeller  Foundation — Continued 

Co-operation  in  Public  Health  Work  in  the  Philippine 

Islands 324-325 

Co-operation  in  Reorganizing  and  Rebuilding  Medical 
Schools  of  Columbia  University  and  the  University  of 

Chicago 326 

Final  Contracts  with  University  College  and  University 

College  Hospital,  London 331-332 

Plan  to  Establish  Fellowships  for  Medical  Teachers  in 

United  States 337 

Report  of  Treasurer 339-409 

Balance  Sheet:  Exhibit  A - .  .  346-347 

Statement  of  Receipts  and  Disbursements  of  Income: 

Exhibit  B 348-350 

Foundation  Appropriations:  Exhibits  C-I 351-364 

Medical  Education:  Exhibit  C 351-354 

Schools  of  Hygiene  and  Public  Health:  Exhibit  D  . . .     355 

Research  in  Physics  and  Chemistry:  Exhibit  E 356 

Mental  Hygiene:  Exhibit  F 357 

Hospital,  Dispensary  and  Nursing  Studies  and  Demon- 
strations: Exhibit  G 358-359 

War  Work:  Exhibit  H 360-361 

Miscellaneous:  Exhibit  1 362-364 

International  Health  Board  Appropriations  :  Exhibit  J  365-376 

China  Medical  Board  Appropriations:  Exhibit  K 377-389 

Summary  of  Appropriations  and  Payments:  Exhibit  L.  .  .  390-391 
Statement  of  Appropriations  and  Payments  of  Special 

Funds  :  Exhibit  M 392 

Statement  of  Principal  Funds:  Exhibit  N 393 

Land,  Buildings,  and  Equipment  Funds:  Exhibit  O.  .  .  ,394-395 
Statement  of  Transactions  Relating  to  Invested  Funds: 

Exhibit  P 396-397 

Schedule  of  Securities  in  General  Funds:  Exhibit  Q  . .  .  398-405 
Schedule  of  Securities  in  Special  Funds:  Exhibit  R  . . .  .406-407 

Rockefeller  Sanitary  Commission 61, 122, 126 

rockhampton,  queensland 169 

Rome,  Italy 333 

Ropes,  William 91 

Rose,  Wickliffe x,  xi,  79,  80,  81,  88, 89 

Rosenwald,  Julius x,  xi,  79 

Rostock,  Germany 333 

Royal  Medical  College  of  Bangkok 320 

RucHUN  Educational  Association,  Hunan 283 

439 


PAGE 

RuLEviLLE,  Sunflower  County,  Mississippi 195 

Russell,  Dr.  F.  F 81,  89,  136,  151,  152 

Russian  Scientists: 

Medical  Journals  Supplied 333 

Ryerson,  M.  a X,  xi,  79 

Sabin,  Dr.  Florence 279 

St.  John's  University,  Shanghai 291,  295 

St.  Pierre  (Hospital,  Brussels) 47 

Salt,  see  Hookworms. 
Salvador: 

Reconstitution  of  National  Health  Organization 134-135 

Fellowships 146 

Also 55, 90, 92, 103, 104, 106, 142, 152, 184 

See  also  San  Salvador,  Salvador;  Sonsonate,  Salvador. 

Salvation  Army,  Halifax,  Nova  Scotia 326 

San  Blas  Indians 143, 181-182 

San  Salvador,  Salvador 204 

Sanatoria,  see  Commission  for  Prevention  of  Tuberculosis  in 
France;  Tuberculosis. 

Santa  Catharina,  Brazil 89 

Santa  Cruz  de  Bravo,  Mexico 105 

Santa  Fe,  New  Mexico 214 

Sao  Paulo  (State)  Brazil: 

County  Health  Service 130 

Also 89, 150, 215 

See  also  Sertaozinho,  County,  Sao  Paulo. 
Sao   Paulo,   University   of,   see  University   of    Sao    Paulo 
(Brazil). 

Sawyer,  Dr.  W.  A 89, 136, 157 

Scarlet  Fever 214 

Schapiro,  Dr.  Louis 90, 93 

Schick  Test  (for  Diphtheria) 211 

Scholarships,  see  Fellowships  and  Scholarships. 
Schools,  see  Children;  County  Health  Work. 

Schools  of  Hygiene 143-145 

Schuffner,  Dr.  Wilhelm 139 

Schweinitz,  Dr.  G.  E.  de 279 

Scott  County,  Kentucky 212-213,  213-214 

Screening  (of  Houses),  see  Malaria  Control. 
Sea-water,  see  Hookworms. 

Segovia,  Dr.  J.  C 152 

Seem,  Dr.  R.  B 258 

440 


PAGE 

Senegal,  Africa 108 

Serbia 8 

Serbian  Commission 50,  335 

Serbs,  Croats,  and  Slovenes,  Kingdom  of 95,  333 

Sertaozinho  County,  Sao  Paulo 215 

Serum,  see  Yellow  Fever. 
Sewage  Disposal  Investigation: 

Expenditures 230-431 

Shantung  Christian  University: 

School  of  Medicine 285-286, 289-291 

Public  Health  Education  Work 306-307 

Shanghai 68,  3 17 

See  also  German  Medical  School,  Shanghai;  St.  John's 
University,  Shanghai. 

Shiga,  Dr.  K 279 

SiA,  Dr.  R.  H.  P 309 

Siam: 

National  Red  Cross  and  Hookworm  Control 136 

Hookworm  Infection  Surveys 170-171 

Medical  Education 315,  317,319 

Public  Health  Organization 317,  319 

Also 7, 48, 62, 68, 90, 93,  317,  323 

Sierra  Leone,  Africa 108 

Singapore 317 

See  also  King  Edward  VII  Medical  School,  Singapore. 

Smallpox 212-213 

Smillie,  Dr.  W.  G 92,  127,  note  129,  140, 

note  141,  142,  156,  158,  180,  185 

Smith  County,  Tennessee 212 

Smyly,  Sir  W.  C 279 

Soil  Sanitation,  see  Latrines. 

Sonsonate,  Salvador 204 

Soper,  Dr.  F.  L 89 

South  America 8, 49,  62,  70 

South  Arcot,  Madras 4 

South  Canara,  Madras 165 

South  Carolina: 

Free  Clinics 212 

Also 91,  111,  150,  187, 191,  note  207 

South  Manchuria  Medical  College,  Mukden 292 

South  Manchuria  Railway  Company 292 

Southern  Baptist  Hospital,  Yangchow,  Kiangsu 299 

Southern  Nigeria 108 

441 


PAGE 

Southern  States: 

Malaria  Control 109-116 

County  Health  Work 112-121, 206-215 

Re-infection  Surveys 121-122 

County  Health  Administration 149-150 

Also 59, 197 

See  also  Malaria  Control. 

Souza,  Dr.  G.  H.  de  Paula 158 

Spain 70, 96 

Spinden,  H.  J 103 

Staley,  F.  S xi,  80 

Stankovic,  Dr.  Radenko 335 

Sugomyia  (Mosquito) 53, 99-100, 104,  200,  203,  204 

Stegomyia  Index,  see  Yellow  Fever. 
Sterilization  of  Carriers,  see  Malaria  Control. 

Stevenson,  Dr.  F.  H 309 

Stifler,  Dr.  W.  W 296 

Stool    Examination    Technique,    see    Hookworm    Disease, 
Diagnosis. 

Stoughton,  N.  F 80 

Straits  Settlements: 

Medical  Education 315,  320,  323 

Also 7, 48, 68, 293,  317 

Strauss,  Frederick x,  xi,  79,  88 

Strode,  Dr.  G.  K 89 

Strongyloid  Larvae  . , 142, 185 

Stuart,  Edward 158 

Sumatra: 

Results  of  Hookworm  Control  Measures 173-174 

Also 139,  317 

Sumter  County,  Alabama 192 

Sunflower  County,  Mississippi 59, 194, 195-196 

Surinam,  see  Dutch  Guiana. 

SwAMiMALAi,  Madras 163 

Sweet,  Dr.  W.  C 89,  93 

Syria 7,  48 

Talladega  County,  Alabama 192 

Tampico,  Mexico 104, 105,  203 

Tanjore,  Madras 163 

Tasmania 121, 166 

Taylor,  Dr.  A.  S 309 

Taylor,  Dr.  H.  A 91 

442 


PAGE 

Tazewell  County,  Virginia 208 

Tennessee 91,  93,  ISO,  152, 187,  note  207,  212 

See  also  Names  of  counties. 

Texas 91,  112,  ISO,  187,  note  207 

See  also  Bullard,  Texas;  Gladstell,  Texas. 

Tirunageswaram,  Madras 163 

Top  Minnow,  see  Fish. 

Toxin-Antitoxin  (for  Diphtheria) 211 

Trachoma 212 

Trichniopoly,  Madras 163 

Trichinopoly  Jail,  Madras 161,  163 

Trinidad  : 

Government  Support  of  Public  Health 131 

Studies  on  Hookworm  Eggs  and  Larvae  in  the  Soil  .  .81-82,  85-86, 

175-176, 179-180 
Modified  Baermann  Apparatus  for  Recovering  Hookworm 

Larvae  from  the  Soil 182-183 

Also 29, 90, 130, 140, 143 

See  also  Princes  Town,  Trinidad. 
Tuberculosis: 

Limitation  to  Control  Work  of   International  Health 

Board : 66 

Sanatorium  in  Porto  Rico 131 

See  also  Commission  for  Prevention  of  Tuberculosis  in 
France. 

Tubingen,  Germany 333 

Tuffier,  Dr.  T 279 

Turin,  Italy 333 

Turkey 7 

Tuscaloosa  County,  Alabama 192 

Tuxpan,  Mexico lOS 

Tuxtepec,  Mexico 56 

Typhoid  Fever 124, 125,  212 

United  Hospital  Fund,  New  York  City 38 

United  States  Bureau  of  Entomology 197, 198 

United  States  Bureau  of  Fisheries 197,  200 

United  States  Bureau  of  Plant  Industry 197 

United  States  Public  Health  Service 27,  28,  33,  59, 

109-110,  150, 187, 196-197, 207 
University  College  Hospital  Medical  School,  London,  49,  331,  337 

University  Grants  Committee  of  Great  Britain SO 

University  of  Alberta,  Edmonton 47,  327,  337 

443 


PAGE 

University  of  Chicago 326 

University  of  Hong  Kong 292-293,  317 

University  of  Indo-China,  Hanoi 323 

University  of  London 35 

University  of  Manitoba,  Winnipeg 327,  337 

University  of  Montreal 47,  327,  337 

University  of  Pennsylvania 29 

University  of  Sao  Paulo  (Brazil): 

Medical  School 34,  67, 144,  337 

University  of  the  Philippines — College  of  Medicine  and 

Surgery 324 

University  of  the  State  of  New  York 261 

University  of  Toronto 327 

Vaccination 212 

Vaccine,  see  Yellow  Fever. 
Vakkampatti,  Madras: 

Percentage  of  Hookworm  Infection 163 

Vandervelde,  Dr.  Paul 334 

Van  Dine,  D.  L 158 

Vaughan,  Dr.  V.  C 80, 88 

Vaughn,  Dr.  E.  I 90, 92,  204 

Venereal  Diseases 211 

Venezuela 53, 107 

Vera  Cruz,  Mexico 53,  56, 105,  203 

Vere  Area,  Jamaica 172-173 

Verhoogen,  Dr.  Rene 334 

Viability  of  Hookworm  Eggs  and  Larvae,  see  Hookworms. 

Victoria,  Australia 166 

Vienna,  Austria 332 

Vincent,  G.  E x,  xi,  79, 80, 81, 88, 158 

Virginia: 

Results  of  Hookworm  Infection  Survey 60-61 

Also 91,  111,  150, 187, 191,  note 207,214 

See  also  Richmond,  Virginia;  Richmond  County,  Virginia; 
Tazewell  County,  Virginia. 

Virginia  State  Board  of  Health 61, 122 

Visiting  Nurses,  see  Public  Health  Nurses. 

Waite,  Dr.  J.  H 169 

Wang,  Dr.  C.  W 280 

Warren,  Dr.  A.  J 90, 158 

Warsaw,  Poland 333 

Washburn,  Dr.  B.  E 90, 142 

444 


PAGE 

Washington  County,  Maryland 28, 151 

Wassell,  Dr.  C.  M 309 

Welch,  Dr.  W.  H 80, 81, 88, 253 

Wells,  Dr.  C.  W 93,  336 

West  Africa 96, 328 

See  also  Yellow  Fever  Commission  to  the  West  Coast  of 
Africa. 
West  Indies 53, 62,  89, 96, 107, 130 

See  also  Names  of  islands. 

West  Virginia 150, 152,  note  207 

Western  Australia 121, 166 

White,  Dr.  J.  H 92 

Wiesbaden,  Germany 333 

Williams,  Dr.  L.  R 92, 120, 158 

Williamson,  C.  C x,  xl,  80 

Williamson  County,  Tennessee 213 

Willis,  Dr.  H.  H 158 

Willis    Salt-Flotation    Method,    see    Hookworm    Disease, 
Diagnosis. 

Wilson,  Dr.  D.  B 91 

Wilson,  Dr.  S.  D 296 

WiNSOR,  Dr.  S.  A 90 

Woo,  Dr.  S.  M 308 

Wood,  Gov.-Gen.  Leonard 324 

Woods,  Dr.  A.  H 310 

Worm  Counts 127, 129, 140, 142 

Wu,  H 309 

WuRZBURG,  Germany 333 

Wyatt,  Dr.  B.  L 92, 158 

Wynaad-Nilgiri  Tea  Estates,  Madras 161 

Yale  Foreign  Missionary  Society 283 

Yangchow,  China,  see  Southern  Baptist  Hospital,  Yangchow, 
Kiangsu. 

Yeager,  Dr.  C.  H 89 

Yellow  Fever; 

Salient  Facts 52-54 

In  Mexico 54 

Use  of  Noguchi  Vaccine  and  Serum 54-55, 108-109 

Work  and  Death  of  H.  B.  Cross 55-57 

Distribution  of  Infection 95-97 

Stegomyia  Index 97, 98, 105 

Use  of  Fish  in  Controlling  Epidemic  in  Peru 99-100,  200,  203 

445 


PAGE 

Epidemics  in  Yucatan 100, 102 

International  Co-operation  in  Control 103-104 

Work  of  National  Departments  of  Health 104 

Mosquito  Control  on  Mexican  Pacific  Coast 105-106 

Infection  in  Brazil 106-107 

Leptospira  icteroides 108 

Use  of  Fish  as  Anti-Mosquito  Measure 200,  203-204 

Use  of  Oil 203 

Expenditures  : 230-231,  238-239 

Also 8, 134-135 

Yellow  Fever  Advisory  Council 91-92 

Yellow  Fever  Commission  to  the  West  Coast  of  Africa.  .  53, 107-108 

Yellow  Fever — First  and  Last,  by  H.  J.  Spinden note    103 

Young,  Dr.  C.  W 309 

Young  Men's  Christian  Association,  China 306 

Young  Women's  Christian  Association,  China 306 

Yquitos,  Peru 107 

Yucatan: 

Center  of  Yellow  Fever  Infection 100, 102 

Yellow  Fever  in  Maya  Civilization 103 

Also 53, 104, 105 

Zagreb,  Jugoslavia 333 


446 


R.W.B.    JACKSON    I  IBRARY 


i 


3    0005    0305SbbS    fl 


061 

R682R 

1921 

Rockefeller  Foundation, 
Report 


Date  Due 

FORM  109